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Evaluation Date
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Client Information
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Client Name
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Address 1
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Gender
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Address 2
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Date of Birth
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City
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Height
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State
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Weight
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Zip Code
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Prognosis
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Client Background
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Referred By
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Date Referred
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Medical History
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General Narrative
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Diagnosis 1
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Diagnosis 2
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Diagnosis 3
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Team Information
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Clinician
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Physician
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Home Environment
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Home Type
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Interior Flooring
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Home Companionship
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Entrance Location
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Entrance Type
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Home Accessibility with Current Mobility
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Type of Mobility Assistive Equipment
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Home Accessibility with Recommended Mobility Equipment Type
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Safely Maneuver Recommended Equipment
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Narrowest Interior Doorway
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Home Safety Check
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1. Working grounded electrical outlet(s)
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2. Home clear of fall hazards
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3. Primary egress accessible
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4. Secondary egress accessible
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5. Working fire alarm
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6. Working fire extinguisher
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7. Home security system
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8. Remote alert system
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Community ADL
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Transportation Type
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Vehicle Accommodation
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Abilities Status
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Cognitives Status
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Comments
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Behavioral Concerns
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Communication Skills
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Memory Skills
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Problem Solving
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Judgment
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Attention
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Vision
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Hearing
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ADL Status
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Dressing
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Comments
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Grooming/Hygiene
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Bathing
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Feeding
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Meal Prep
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Home Management
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Toileting
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Bowel Management
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Bladder Management
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Mobility Skills
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Ambulation
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Comments
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Falls?
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Uses Device?
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Wheelchair-Bed Transfer
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Wheelchair-Commode Transfer
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Wheelchair-Floor Transfer
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Manual Wheelchair Propulsion
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Operate Power Wheelchair w/Std. Joystick
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Operate Power Wheelchair w/Alt. Controls
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Skin Integrity
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Risk for Skin Breakdown
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Skin Breakdown History
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Sensation Status
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Ability to Perform Weight Shifts While Seated
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Hours in Wheelchair Per Day
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Seated Weight Bearing Surface
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Assessment Questions
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Does your client have a mobility limitation that impairs participation in MRADLs in the home
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Answer
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Comments
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Can their limitations be compensated by the addition of MAE to improve the ability to participate in MRADLs in the home?
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Answer
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Comments
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Is your client or their caregiver capable and willing to operate the MAE safely in the home?
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Answer
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Comments
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Can their mobility deficit be safely resolved by a cane or walker?
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Answer
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Comments
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Does your client's home environment support the use of the recommended equipment? (Home assessment to be completed by MES)
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Answer
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Comments
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Does your client have the upper extremity function to safely propel a manual wheelchair to participate in MRADLs in the home?
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Comments
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