Occupational Therapist Template

Power Wheelchair Assessment - Virtual

A professional Occupational Therapist template for healthcare professionals.

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Specialty

Occupational Therapist

Used

18 times

Type

Note

Last edited

2025/03/02

Created by

Alexandra Bowen

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About this template

The Power Wheelchair Assessment - Virtual template is designed for occupational therapists to evaluate patients' needs for a power wheelchair. This comprehensive template covers patient information, medical history, current mobility status, home accessibility, and detailed wheelchair specifications. It ensures that all aspects of the patient's environment and physical capabilities are considered for optimal wheelchair fitting and home modifications. This template is ideal for clinicians conducting virtual assessments, providing a structured approach to document and recommend necessary interventions for improved patient mobility and independence.

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Patient Information Johnathan Smith 123456789 15 March 1965 Reason for Visit Johnathan requires a power wheelchair due to severe osteoarthritis, which limits his mobility and causes significant pain when using manual aids. Medical History - Osteoarthritis - Hypertension - Total knee replacement in 2018 Current Mobility Status Johnathan currently uses a manual wheelchair, but experiences fatigue and difficulty navigating uneven surfaces. Home Assessment The home entrance has three steps, and there is no existing ramp. The garage is not wheelchair-accessible. Proposed solutions include installing a ramp at the main entrance. Power Wheelchair Assessment Johnathan demonstrated ease of use with the power wheelchair, though adjustments are needed for posture. - Seat width: 18 inches - Seat depth: 20 inches - Seat to floor height: 19 inches - Backrest height: 22 inches - Cushion type: Gel cushion for pressure relief - Footrest adjustments: Required for optimal comfort Patient Physical Assessment - Height: 175 cm - Weight: 85 kg - Upper body mobility: Adequate for power wheelchair operation - Cognitive assessment: No impairments noted Recommendations - Proposed power wheelchair specifications: Model X200 with custom gel cushion and adjustable footrests - Suggested home modifications: Install a ramp at the main entrance and widen doorways for accessibility Follow-up - Next steps for application process: Complete funding application and submit necessary documentation - Instructions for accessible ramp planning: Consult with a contractor for ramp installation Payment Information - Payment method: Insurance coverage with supplemental government funding - Billing details: Invoice to be sent to insurance provider