CLINICAL FUNCTIONAL MOBILITY EVALUATION
POWER MOBILITY
Patient Name: ______
Address: ______
City: ______State: ______Zip: ______
DOB: ______Age: ______Male: ____ Female: ____
DX: ______Onset Date: ______
Insurance: ______
Referring MD: ______
Goals:
1. Goals of Mobility/Base Seating System:
Allow Participation in MRADLs Accommodate slow progression of deformity
Reduce incidence of skin breakdown Provide total body comfort/increase sitting tolerance
Improve Independent function Improve sitting balance
Improve mobility Promote/improve alignment
Other ______
2. Participation Goals: MRADLs with use of recommended device
How will the provision of recommended equipment improve patient’s ability to accomplish MRADLs?
(i.e. bathing, toileting, eating, cooking, cleaning, other self care and household tasks)
______
______
Brief Medical History/Current Symptoms:
______
Clinical Progression/Recent Change in Medical Condition:
______
Please list existing equipment and why it is no longer functional or medically necessary:
Make: ______Model: ______Serial#: ______
______
A. EVALUATION IS FOR:
New Equipment Replacement Equipment Modifications to Current Equipment
Patient has caregiver: Yes No
Caregiver is able and willing to participate in use of mobility equipment: Yes No
Caregiver limitation: ______
Patient spends time without caregiver: Yes No Number of hours alone: ______
Patient Name: ______
B. FUNCTIONAL ASSESSMENT:
What is this patient’s mobility limitation and how does it interfere with the performance of activities of daily living?
1. Ambulation Status/Mobility Limitation:
Non-ambulatory
Limited ambulation:
Patient is able to independently and safely ambulate:
______feet maximum without stopping
______feet on level surfaces or ______feet on varied surfaces (i.e. uneven terrain, inclines)
______feet using current mobility equipment: ______
Speed: functional non-functional
Balance: adequate for safe ambulation unsafe
In-Home mobility: Can the patient ambulate to all areas of the home: Yes No
Comments: ______
2. Current limitations in accomplishment of MRADLs include (i.e. bathing, toileting, eating, cooking, cleaning, other self care and household tasks):
______
______
______
Which of the following conditions impact the patient’s ability to ambulate and independently, safely and in a timely manner participate in mobility related activities of daily living? Check all that apply:
weakness imbalance fatigue/poor endurance
loss of range of motion history of falls compromised respiratory
lack of coordination/motor skills vision/hearing deficit impaired judgment
cognitive deficit pain other: ______
Comments: ______
3. Transfer Status:
Transfer Method: ______Assistive Device Used: ______
______
Can the patient perform the following transfers:
Bed: Independent Min. Assist Mod. Assist Max. Assist Dependent
Chair: Independent Min. Assist Mod. Assist Max. Assist Dependent
Mobility Device: Independent Min. Assist Mod. Assist Max. Assist Dependent
C. PHYSICAL EXAM/MEDICAL STATUS:
1. Posture and flexibility of the pelvis, trunk and neck:
Pelvis: Posture: posterior tilt anterior tilt rotation obliquity flexible fixed
Trunk: Posture: scoliosis kyphosis lordosis rotation flexible fixed
Neck: Posture: forward flexion extension lateral flexion flexible flexible
2. Coordination/Motor Control:
Briefly describe the patient’s control of:
Upper Extremities: ______
Lower extremities: ______
3. Balance:
Sitting Balance: Independent With Support
Standing Balance: Independent With Support
Limitations UE LE Spine Other: ______
4. Skin Integrity:
Patient is: Self Positioning Decreased self positioning status Non-self positioning
Skin breakdown present: Stage: ______Location(s): ______
History of pressure ulcers: Yes No Chronic
Other risk factors (Check all that apply)
Bony prominences Impaired nutrition status Fecal or urinary incontinence Compromised circulatory status
Patient Name: ______
D. EQUIPMENT RECOMMENDATIONS:
1. Is a cane, crutches or walker recommended? Yes No
If no, why can’t a cane, crutches or walker meet this patient’s mobility needs in the home?
Inadequate Motor Skills/Coordination Inadequate Endurance Inadequate Strength
Other: ______
2. Is a manual wheelchair base recommended? Yes No
If no, please check why a manual wheelchair can’t meet this patient’s mobility needs in the home:
Inadequate Motor Skills/Coordination Inadequate Endurance Inadequate Strength
Other: ______
IF YES, STOP, ORDER MANUAL WHEELCHAIR
IF NO, PROCEED TO POWER MOBILITY DEVICE JUSTIFICATION
** Power Mobility Device – Justification
1. Is the patient a candidate for a Power Mobility Device? Yes No
2. Does the patient have the physical, cognitive and sensory abilities to operate a Scooter (POV)
or Power Wheelchair safely within the home? Yes No
3. Is the patient willing and motivated to use the Scooter (POV) or Power Wheelchair? Yes No
a. Is a Scooter (POV) appropriate? Yes No
If no, why can’t a Scooter (POV) meet this patient’s mobility need in the home?
Inadequate Motor Skills/Coordination Inadequate Endurance Inadequate Strength
Turning Radius Too Large for Home Other: ______
b. Is a Power Wheelchair recommended: Yes No
Additional Notes/Justification:
______
______
______
SIGNATURES:
Service Provider:
PT/OT Name (Print): ______Facility: ______
______Phone: ______
Street Address: ______City: ______State: ______Zip: ______
(By signing below, I attest that I have no financial relationship with the PMD Supplier)
PT/OT Signature: ______Date: ______
Physician:
Physician Name (Print): ______NPI: ______UPIN: ______
Street Address: ______City: ______State: ______Zip: ______
Phone: ______
Date of Face to Face with my Patient: ______
(Face to Face date only needed for Medicare patient’s obtaining Powered Mobility Devices)
(By signing below, I concur with the above evaluation)
Physician Signature: ______Date: ______
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