College for Vocational Training Wheelchair assessment and referral form Instructions A current wheelchair assessment of a wheelchair must be conducted by a Physiotherapist must be completed for or modifications (including new system seating’s) Information First name - Last Name- Date of Birth- Date of Assessment- Height - Weight- Diagnosis- I Neurological factors Indicative muscle tone: Hypertonic Hypotonic Abs. Fluctuating others Describe muscle tone: Describe active movements affected by muscle tone: Describe passive movements affected by muscle tone: Describe reflexes present(if any): II. Postural Control Head control Good Fair Poor None Trunk control Good Fair Poor None Upper extremities Good Fair Poor None Lower extremities Good Fair Poor None Description and pictoral representation of posture:
How do we measure the clients ability for the wheel chair use? It is a big question for the rehabilitation professionals and the answer is simple the western world says by assessments. I have used a western world assessment tool and did some modification in it. This was the tool that I was using to document the clients ability for the wheelchair use and referral. We in India in disability sector has limited resources and we need to think of methods to develop our skills in rehabilitation. I feel by sharing our skills we may do so. If you have any similar tools, do share it in the forum. If you have any suggestions ro comments please share with me at [email protected]
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
College for Vocational Training Wheelchair assessment and referral form
InstructionsA current wheelchair assessment of a wheelchair must be conducted by a Physiotherapist must be completed for or modifications (including new system seating’s)
InformationFirst name - Last Name-Date of Birth- Date of Assessment-Height - Weight-Diagnosis-
Describe active movements affected by muscle tone:
Describe passive movements affected by muscle tone:
Describe reflexes present(if any):
II. Postural ControlHead control Good Fair Poor None Trunk control Good Fair Poor None Upper extremities Good Fair Poor None Lower extremities Good Fair Poor None Description and pictoral representation of posture:
III.Medical surgical history and plans:Is there any history of decubitus/skin breakdown? Yes No If yes please explain:
Describe orthopedic conditions and/ or range of motion requiring special consideration (i.e., contractures, degree of spinal curvature, etc.):
Describe other physical limitation or concerns (i.e., respiratory):
Describe any recent changes in medical/Physical/functional status:
Brief description if the child/adult has undergone any surgery:
IV. Functional assessmentAmbulatory status: Non ambulatory With assistance Short distance only Community ambulatoryDescription:
Indicate the child’s /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 NoIf No, please explain:
Indicate the child/adults transfer capacities: Maximum assistance Moderate assistance Minimum assistance None Notes:
Is the child/adult tube fed? Yes NoIf yes please explain:
Feeding: Maximum assistance Moderate assistance Minimum assistance None Notes:
Dressing: Maximum assistance Moderate Minimum assistance None Notes: He needs full assistance in dressing and undressing.
Describe the activities performed in wheelchair: (Mobility,feeding,socializing with peers, school, home, family, engaging in community activity)
TRANSPORTATION:
Car Van Bus Bike Other: Sits in wheelchair during transport
Where is w/c stored during transport? Tie Downs
Self Driver Drive while in Wheelchair yes noEmployment:Specific requirements pertaining to mobility School:Specific requirements pertaining to mobility
Other:
FUNCTIONAL/SENSORY PROCESSING SKILLS:Handedness: Right Left NA Comments:
Functional Processing Skills for Wheeled MobilityProcessing Skills are adequate for safe wheelchair operation
Comments:
COMMUNICATION:Verbal Communication WFL receptive WFL expressive Difficult to understand non-communicative