Stable Deteriorating Improving Current medical status Details (e.g. walking aids, distance): Mobility indoors Details (e.g. walking aids, distance): Mobility outdoors Details (e.g. aid): Transfers Details (e.g. grade, location, duration of sores): Pressure areas Details (e.g. ROM, strength, to self-propel): Use of arms Details (e.g. contractures, ROM): Use of legs Details (e.g. tilt, obliquity, rotation): Pelvic alignment Details (e.g. forward flexion, lateral tilt): Head position Details (e.g. static & dynamic): Sitting balance Cognitive / Perceptual Details (e.g. memory, neglect, learning difficulty): deficits Details (e.g. hemianopia, glasses): Visual deficits SECTION 5 ENVIRONMENTAL & SOCIAL FACTORS ENVIRONMENTAL FACTORS Flat Details (e.g. ownership, level): Type of accommodation? House Other Has a home visit been carried Yes out? No (Please attach relevant reports) Details (e.g. turning space, narrow doorways, steps): Is the home wheelchair Yes accessible? No SOCIAL FACTORS Yes with family 24 hour care Other Does client live alone? No Yes Details (e.g. frequency, number of carers): Is there a care package in place? No User Who will push the wheelchair? Family/Carer Does the carer have any health Yes Details: concerns? No TYPE OF (ANTICIPATED) USAGE Frequency: Daily Weekly Monthly Duration: 1-4 hours 4-8 hours All day Client Name: NHS no: SECTION 6 ACTUAL USER MEASUREMENTS inches cm
Current medical status Stable Deteriorating Improving Mobility indoors Details (e.g. walking aids, distance): Mobility outdoors Details (e.g. walking aids, distance): Transfers Details (e.g. aid): Pressure areas Details (e.g. grade, location, duration of sores): Use of arms Details (e.g. ROM, strength, to self-propel): Use of legs Details (e.g. contractures, ROM): Pelvic alignment Details (e.g. tilt, obliquity, rotation): Head position Details (e.g. forward flexion, lateral tilt): Sitting balance Details (e.g. static & dynamic): Cognitive / Perceptual deficits Details (e.g. memory, neglect, learning difficulty): Visual deficits Details (e.g. hemianopia, glasses): SECTION 5 ENVIRONMENTAL & SOCIAL FACTORS ENVIRONMENTAL FACTORS Type of accommodation? Flat House Other Details (e.g. ownership, level): Has a home visit been carried out? (Please attach relevant reports) Yes No Is the home wheelchair accessible? Yes No Details (e.g. turning space, narrow doorways, steps): SOCIAL FACTORS Does client live alone? Yes No with family 24 hour care Other Is there a care package in place? Yes No Details (e.g. frequency, number of carers): Who will push the wheelchair? User Family/Carer Does the carer have any health concerns? Yes No Details: TYPE OF (ANTICIPATED) USAGE Frequency: Daily Weekly Monthly Duration: 1-4 hours 4-8 hours All day Client Name: NHS no: SECTION 6 ACTUAL USER MEASUREMENTS inches cm
wheelchair-referral-form-therapists.docx