Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Hypotonic
Abs.
Fluctuating
No
others
Describe orthopedic conditions and/ or range of motion requiring special consideration (i.e., contractures,
degree of spinal curvature, etc.):
Indicate the childs /adults ambulatory potential: Already using a wheel chair
Expected in 1 year Not expected Expected in future __ Years.
Description:
IV. Functional assessment:
Is the child/adult totally dependent on W/C? Yes
If No, please explain:
No
No
Moderate assistance
Minimum assistance
None
None
Describe the activities performed in wheelchair: (Mobility,feeding,socializing with peers, school, home, family,
engaging in community activity)
TRANSPORTATION:
Car
Van
Bus
Bike
Other
yes
no
School:
Specific requirements pertaining to mobility
Other:
COMMUNICATION:
Verbal Communication
WFL receptive
WFL expressive
Difficult to understand
non-communicative
Hypersensate
Defensiveness
Level of sensation:
Skin Issues/Skin Integrity
Current Skin Issues
Yes
Intact
Red area
Scar Tissue
No
Open Area
Where ___________________________
Pressure Relief:
Able to perform effective pressure relief :
Method:
If not, Why?:
Yes
No
Where
________________________
When
_________________________
Yes
No
Assist
Unable
Indep
with
Equip
Not
assessed
Comments
Dressing
Eating
Grooming/Hygiene
Meal Prep
IADLS
Bowel Mngmnt:
Continent
Incontinent
Accidents
Comments:
Bladder Mngmnt:
Continent
Incontinent
Accidents
Comments:
None
Dependent
Manual
Scooter
V. Environmental assessment
Describe the place where Wheel chair is going to be used(home/school):
No
Needs modification
RECOMMENDATION / GOALS :
POV
POWER WHEELCHAIR:
MANUAL WHEELCHAIR
POSITIONING SYSTEM(TILT/RECLINE)
SEATING
WHEELCHAIR SKILLS:
Indep
Assist
Dependent/
unable
N/A
Comments
Operate Scooter
UE or LE strength and
Arm :
left
right
endurance sufficient to participate in
Foot:
left
right
ADLs using manual wheelchair
Strength, hand grip, balance , transfer appropriate for use.
Both
Both
Safe
Functional
Distance
Safe
Functional
Distance
MOBILITY/BALANCE:
Balance
Transfers
Ambulation
Sitting Balance:
Standing Balance
Independent
Independent
Min Assist
Min assist
Mod Asst
Min Assist
Mod assist
Max assist
Mod Assist
Max assist
Dependent
Unable to Ambulate
Unable
Sliding Board
WFL
Uses UE for balance in sitting
Max Assist
Unable
Comments:
WFL
MAT EVALUATION
A
F
B
D
I
J
K L
E
M
N
A:
B:
C:
D.
E.
F.
G.
++
Measurements in Sitting:
Shoulder Width
Chest Width
Chest Depth (Front Back)
Hip width
Between Knees
Top of Head
Occiput
Overall width (asymmetrical width for
windswept legs or scoliotic posture
Left
Right
H:
I:
J:
K:
L:
M:
N:
O: Foot Length
Additional Comments:
COMMENTS:
POSTURE:
Anterior / Posterior
Obliquity
Rotation-Pelvis
P
E
L
V
I
S
Neutral
Anterior
Posterior
Fixed
WFL
R elev
Fixed
Other
Other
l elev
WFL
Right
Anterior
Fixed
Other
Partly Flexible
Partly Flexible
Partly Flexible
Flexible
Flexible
Flexible
TRUNK
Anterior / Posterior
Left
Anterior
Left Right
Neutral
WFL Thoracic
Lumbar
Kyphosis
Lordosis
WFL
Convex
Convex
Left
Right
c-curve
s-curve
Left-anterior
Right-anterior
multiple
Fixed
Flexible
Fixed
Partly Flexible
Other
Partly Flexible
Flexible
Fixed
Flexible
Partly Flexible
Other
Other
Position
Windswept
Hip Flexion/Extension
Limitations:
H
I
P
S
Neutral
Abduc ADduct
Fixed
Fixed
Other
Subluxed
Partly Flexible
Partly Flexible
Hip Internal/External
Range of motion Limitations:
Dislocated
Flexible
Knee
Flexible
R.O.M.
Foot Positioning
Left
KNEES
&
Right
WFL
WFL
Dorsi-Flexed
Plantar Flexed
Inversion
Eversion
ROM concerns:
WFL
Limitations
Limitations
FEET
COMMENTS:
Posture:
Good Head Control
HEAD
Functional
&
NECK
Flexed
Extended
Rotated L
Lat Flexed
Rotated R
at Flexed
Describe Tone/Movement
of head and Neck:
L
R
Cervical Hyperextension
Upper
Extremity SHOULDERS
Left
Right
Functional
Functional
elev / dep
pro-retract
retract
subluxed
elev / dep
prosubluxed
UE Strength Concerns:
N/A
None
Concerns:
R.O.M.
ELBOWS
Left
Right
Describe
Tone/Movement of UE:
Strength concerns:
Left
Right
Strength / Dexterity:
WRIST
&
HAND
Fisting
Seat Cushion
Manuf/mod/size
Justification
accommodate impaired
stabilize pelvis
sensation
accommodate obliquity
decubitus ulcers present
accommodate multiple
prevent pelvic extension
deformity
low maintenance
neutralize LE
increase pressure
distribution
Seat Wedge
accommodate ROM
Cover Replacement
Mounting
hardware
lateral trunk supports
headrest
medial thigh support
back
seat
Provide increased
aggressiveness of seat shape
to decrease sliding down in the
seat
Seat Board
Back Board
Back
mount headrest
swing medial thigh
support away
allows attachment of
cushion to mobility base
Lateral pelvic/thigh
support
pelvis in neutral
accommodate pelvis
position upper legs
Medial Knee
Support
Foot Support
decrease adduction
accommodate ROM
position foot
accommodate deformity
stability
decrease tone
control position
Ankle strap/heel
loops
Lateral trunk
Supports
Anterior chest
strap, vest, or
shoulder retractors
Component
Headrest
Manuf/mod/size
Justification
provide posterior head support
improve respiration
Neck Support
Upper
Extremity
Support
placement of switches
safety
accommodate ROM
accommodate tone
improve visual orientation
decrease edema
decrease subluxation
control tone
provide work surface
placement for
AAC/Computer/EADL
Pelvic
Positioner
Belt
SubASIS bar
Dual Pull
stabilize tone
decrease falling out of chair/
**will not decrease potential for
sliding due to pelvic tilting
prevent excessive rotation
Bag or pouch
Holds:
medicines
orthotics
changes
Arm trough
Posterior hand
support
tray
full tray
swivel mount
Other
special food
clothing
diapers
catheter/hygiene
ostomy supplies
Signature of the PT