Other: Other: Max Assistance Other: Dependent * ID NUMBER: *INDIVIDUAL’S NAME: 14. Ambulation Independence: Independent Requires assistance with ambulation Non-ambulatory Varied ambulation skills; see completed table LEVEL ASSISTANCE SPEED DISTANCE ENDURANCE SPECIFY AMBULATION AIDE WNL < 5 min None Independent < 10 ft Slow 5 – 10 min Assistance with Ambulation 10 – 30 ft 10 – 30 min Non-Ambulatory 30 – 100 ft Carpet > 30 min > 100 ft Other: Other: WNL < 5 min None Independent < 10 ft Slow 5 – 10 min Assistance with Ambulation 10 – 30 ft 10 – 30 min Smooth Non-Ambulatory 30 – 100 ft > 30 min > 100 ft Other: Other: None WNL < 5 min Independent < 10 ft Slow 5 – 10 min Assistance with Ambulation 10 – 30 ft Uneven 10 – 30 min Terrain Non-Ambulatory 30 – 100 ft (outside) > 30 min > 100 ft Other: Other: 15. Coordination, Motor Control, and Balance ACTIVITY UNSUPPORTED MOTOR CONTROL COMMENTS / OTHER Sitting Balance (Static) Steady, safe Leans or slides Unable Upper Extremity Mild/Moderate Functional Dependent Gross Motor Control Impairment Upper Extremity Fine Mild/Moderate Functional Dependent Motor Control Impairment 16. Range of Motion (Attach data as appropriate) AREA AFFECTED RANGE OF MOTION LIMITATIONS RELATIVE TO SEATING Right Upper Extremity Left Upper Extremity Right Lower Extremity Left Lower Extremity
Other: Other: Max Assistance Other: Dependent *INDIVIDUAL’S NAME: * ID NUMBER: 14. Ambulation Independence: Independent Requires assistance with ambulation Non-ambulatory Varied ambulation skills; see completed table LEVEL ASSISTANCE SPEED DISTANCE ENDURANCE SPECIFY AMBULATION AIDE Carpet Independent WNL < 10 ft < 5 min None Assistance with Ambulation Slow 10 – 30 ft 5 – 10 min Non-Ambulatory 30 – 100 ft 10 – 30 min > 100 ft > 30 min Other: Other: Smooth Independent WNL < 10 ft < 5 min None Assistance with Ambulation Slow 10 – 30 ft 5 – 10 min Non-Ambulatory 30 – 100 ft 10 – 30 min > 100 ft > 30 min Other: Other: Uneven Terrain (outside) Independent WNL < 10 ft < 5 min None Assistance with Ambulation Slow 10 – 30 ft 5 – 10 min Non-Ambulatory 30 – 100 ft 10 – 30 min > 100 ft > 30 min Other: Other: 15. Coordination, Motor Control, and Balance ACTIVITY UNSUPPORTED MOTOR CONTROL COMMENTS / OTHER Sitting Balance (Static) Steady, safe Leans or slides Unable Upper Extremity Gross Motor Control Functional Mild/Moderate Impairment Dependent Upper Extremity Fine Motor Control Functional Mild/Moderate Impairment Dependent 16. Range of Motion (Attach data as appropriate) AREA AFFECTED RANGE OF MOTION LIMITATIONS RELATIVE TO SEATING Right Upper Extremity Left Upper Extremity Right Lower Extremity Left Lower Extremity
Wheeled_Mobility_Device_LMN_Form.docx