MOBILITY EQUIPMENT ASSESSMENT
<patient date of birth>
<patient height in ft. and inch.>
<patient weight in lbs.>
RELATED MEDICAL HISTORY
I. SUBJECTIVE INFORMATION
<patient name> is a <patient age> year old who was referred for assessment of <his/her> mobility and posture deficits. <patient name> presents today for consultation by a certified equipment specialist with regard to <his/her> request for new mobility related equipment. <patient name> reports medical history that is significant for mobility related ADL deficits. <He/She> is affected by physical limitations secondary to <his/her> medical diagnosis and demonstrates limitations in physical ability to ambulate. <He/She> is unable to complete MRADL's without adaptive equipment. <He/She> was put in contact with my company to obtain this consultation for new mobility related equipment. <patient name> reports that <he/she> is unable to complete mobility related activities of daily living secondary to <his/her> mobility impairment.
A. Based on the findings of this assessment, <patient name> 's medical condition has resulted in a need to receive adaptive equipment as recommended. This device as specified was found to be most appropriate, reasonable and accessible to meet <his/her> needs. It is reasonable to conclude that the equipment as recommended will maximize potential to normalize and improve <his/her> medical condition.
B. EXPECTED LENGTH OF NEED: Lifetime
III. EXPECTED OUTCOME
Lower level equipment is not appropriate for due to the physical barrier that would result in limits for performing MRADL's efficiently, effectively or within a reasonable time frame. As a person who is dependent on adaptive equipment for mobility, <he/she> requires a device that promotes healthy posture and pressure management. will spend a majority of the day positioned in the recommended wheelchair. There are no less costly alternatives that provide <him/her> with the opportunity to achieve independence goals. 's height and weight are within the manufacturer's specifications for safe use of this device.
<RTS name and title>
cc: <therapist name and title>
cc: <physician name and title>