Powered mobility practical assessment form

This practical assessment is performed in addition to the initial assessment for a powered mobility aid with trial equipment.

Client name:DOB:

Clinician:Agency:

Equipment trialled:

 Pre-prescription trial

 Post-prescription trainingDate of Ax/Training:

RATING SCALE:

3Optimal performance:Able to perform task in one attempt smoothly and safely.

2Partially competent:Completes task hesitantly, requires several tries, requires speed restriction and/or bumps wall/objects lightly (without causing harm).

1Incompetent:Bumps people or objects in a way that causes or could cause harm to driver, other person or to objects.

0Unable to complete task:Provide reason e.g. requires constant verbal and/or visual cues or physical assistance.

N/ANot assessed/Not applicable

Transfers / Ax rating / Re Ax rating / Comments
Able to transfer and position correctly in seat
Able to move armrest
Able to swing away and put footplates up/down
Able to alter joystick/tiller position
Able to use swivel lever under seat
Able to reach/use walking aid to assist transfer
Seating/Positioning / Ax rating / Re Ax rating / Comments
Posture in chair
Dynamic sitting balance
Head position
Upper limb position
Lower limb position
Comfort (after 20 mins)
Use of controls / Ax rating / Re Ax rating / Comments
On/off – use of key/switch
Speed controls
Horn/lights
Joystick/hand controls
Other (e.g. switching, tilt, recline, suck/blow)
Disengaging for free wheel
Driving Skills / Ax rating / Re Ax rating / Comments
Start/stop (reaction time)
Can drive forward (maintain straight line)
Turning left and right on cue
Observation skills (turning head)
Manoeuvres around obstacles
Reversing e.g. open and tight spaces
Demonstrates 3-point turn
Demonstrates “U” turn
Demonstrates difference between fast and slow
Appropriate speed control e.g. slows down when negotiating kerb or ramp
Ability to negotiate kerb/ramp safely
Road Skills – tested in local community ONLY if driving skills passed safely / Ax rating / Re Ax rating / Comments
Location/type of terrain around home
Up/down footpath kerb,
negotiates narrow path safely
Abiding by pedestrian road rules (e.g. gives way)
Negotiates difficult terrain safely e.g. grass, pebbles, rough road
Crosses road safely at intersection with traffic lights
Crosses road safely at intersection without traffic lights
Other
Judgment/Cognitive Skills / Ax rating / Re Ax rating / Comments
Understood and followed instructions and recommendations of the assessor
Displays appropriate awareness and monitoring of safety hazards
Maintains concentration - is not easily distracted
Is able to appropriately judge space and distance
Maintains appropriate behaviour (not aggressive or abusive)
Responds in appropriate time
Home Access – for indoor use and/or for charging / Ax rating / Re Ax rating / Comments
Can access home safely
Can drive safely through doorways/hall
Negotiates obstacles safely
Transfers safely onto toilet/chairs/bed
Is able to manoeuvre safely inside rooms
Is able to plug in charger
Is able to read the battery level indicator

RECOMMENDATION:

Powered mobility aid to be issued

  • Client is able to drive powered mobility aid safely and independently
  • Managed above tasks safely and independently
  • Required minimal assistance however, carer is able to safely assist

Further training required

Recommended training programme:

Conditional use of powered mobility aid (contract to be completed)

  • Client agrees not to use powered mobility aid if supervision/assistance is not available
  • Can be used indoors safely, but needs to be supervised on the road
  • Home use only

Powered mobility aid is not safe to be issued

  • Client observed to drive dangerously or aggressively
  • Client not receptive to changing poor driving habits (e.g. lacks insight, impulsive)
  • Client not willing to be trained or supervised as needed

Comments:

Clinician’s Name:

Clinician’s Signature:Date:

1 / DFC EP/ Children & Adults: Powered mobility practical assessment form 9/3/11