1.
College for Vocational Training
Wheelchair assessment and referral form
Instructions
A current wheelchair assessment of a wheelchair must be conducted by a Physiotherapist must be completed for
or modifications (including new system seating’s)
Information
First name - Last Name-
Date of Birth- Date of Assessment-
Height - Weight-
Diagnosis-
I Neurological factors
Indicative muscle tone: Hypertonic Hypotonic Abs. Fluctuating others
Describe muscle tone:
Describe active movements affected by muscle tone:
Describe passive movements affected by muscle tone:
Describe reflexes present(if any):
II. Postural Control
Head control Good Fair Poor None
Trunk control Good Fair Poor None
Upper extremities Good Fair Poor None
Lower extremities Good Fair Poor None
Description and pictoral representation of posture:
III.Medical surgical history and plans:
Is there any history of decubitus/skin breakdown? Yes No
If yes please explain:

2.
Describe orthopedic conditions and/ or range of motion requiring special consideration (i.e., contractures,
degree of spinal curvature, etc.):
Describe other physical limitation or concerns (i.e., respiratory):
Describe any recent changes in medical/Physical/functional status:
Brief description if the child/adult has undergone any surgery:
IV. Functional assessment
Ambulatory status: Non ambulatory With assistance Short distance only
Community ambulatory
Description:
Indicate the child’s /adults ambulatory potential: Already using a wheel chair
Expected in 1 year Not expected Expected in future __ Years.
Description:
IV. Functional assessment:
Is the child/adult totally dependent on W/C? Yes No
If No, please explain:
Indicate the child/adults transfer capacities: Maximum assistance
Moderate assistance Minimum assistance None
Notes:
Is the child/adult tube fed? Yes No
If yes please explain:
Feeding: Maximum assistance Moderate assistance Minimum assistance None
Notes:

3.
Dressing: Maximum assistance Moderate Minimum assistance None
Notes: He needs full assistance in dressing and undressing.
Describe the activities performed in wheelchair: (Mobility,feeding,socializing with peers, school, home, family,
engaging in community activity)
TRANSPORTATION:
Car Van Bus Bike Other : Sits in wheelchair during transport
Where is w/c stored during transport? Tie Downs
Self Driver Drive while in Wheelchair yes no
Employment:
Specific requirements pertaining to mobility
School:
Specific requirements pertaining to mobility
Other:
FUNCTIONAL/SENSORY PROCESSING SKILLS:
Handedness: Right Left NA Comments:
Functional Processing Skills for Wheeled Mobility
Processing Skills are adequate for safe wheelchair operation
Comments:
COMMUNICATION:
Verbal Communication WFL receptive WFL expressive Difficult to understand non-communicative
Uses an augmentative communication device
AAC Mount Needed:
SENSATION and SKIN ISSUES:
Sensation Pressure Relief:
Intact Impaired Absent Able to perform effective pressure relief : Yes No
Hyposensate Hypersensate Method:
If not, Why?:
Defensiveness
Level of sensation:
Skin Issues/Skin Integrity
Current Skin Issues Yes No History of Skin Issues Yes Hx of skin flap surgeries Yes No
Intact Red area Open Area No Where ________________________
Where When _________________________
Scar Tissue At risk from prolonged sitting
Where ___________________________ ________________________
When
_________________________

4.
Complaint of Pain: Please describe
ADL STATUS (in reference to wheelchair use):
Indep Assist Unable Indep Not Comments
with assessed
Equip
Dressing
Eating Describe oral motor skills
Grooming/Hygiene
Meal Prep
IADLS
Comments:
Bowel Mngmnt: Continent Incontinent Accidents
Comments:
Bladder Mngmnt: Continent Incontinent Accidents
CURRENT SEATING / MOBILITY:
Current Mobility Base: None Dependent Dependent with Tilt Manual Scooter Power Type of Control:
Current Condition of Mobility Base:
Current Seating System: Age of Seating System:
COMPONENT MANUFACTURER/CONDITION
Seat Base
Cushion
Back
Lateral trunk supports
Thigh support
Knee support
Foot Support
Foot strap
Head Support
Pelvic Stabilization
Anterior Chest/Shoulder
Support
UE Support
Other
When relevant: Overall seat height Overall w/c length Overall w/c width
Describe posture in
present seating system:
V. Environmental assessment
Describe the place where Wheel chair is going to be used(home/school):

5.
Is the home/School accessible for W/C? Yes No
Are there ramps in home/School? Yes No Needs modification
RECOMMENDATION / GOALS :
MANUAL WHEELCHAIR  POV POWER WHEELCHAIR: POSITIONING SYSTEM(TILT/RECLINE) SEATING
WHEELCHAIR SKILLS:
Indep Assist Dependent/ N/A Comments
unable
Bed ↔ w/c Chair Transfers
w/c ↔ Commode Transfers 
Manual w/c Propulsion:
UE or LE strength and Arm : left right Both
endurance sufficient to participate in Foot: left right Both
ADLs using manual wheelchair
Operate Scooter
Strength, hand grip, balance , transfer appropriate for use.
Living environment appropriate for scooter use.
Operate Power w/c: Std. Joystick
Safe Functional Distance
Operate Power w/c: w/ Alternative
Controls
Safe Functional Distance
MOBILITY/BALANCE:
Balance Transfers
Ambulation
Sitting Balance: Standing Balance
Independent Independent
WFL WFL Min Assist Ambulates with Asst
Uses UE for balance in sitting Min assist Mod Asst Ambulates with Device
Min Assist Mod assist Max assist Indep. Short Distance Only
Mod Assist Max assist Dependent Unable to Ambulate
Max Assist Unable Sliding Board
Unable Lift / Sling Required
Comments:

6.
MAT EVALUATION :
A
F
G C
H B
I D
J
K L
E
M
N
O
Measurements in Sitting: Left Right
A: Shoulder Width
B: Chest Width H: Seat to Top of Shoulder
C: Chest Depth (Front – Back) I: Acromium Process (Tip of Shoulder)
D. Hip width J: Inferior Angle of Scapula
E. Between Knees K: Seat to Elbow
F. Top of Head L: Seat to Iliac Crest
G. Occiput M: Upper leg length
++ Overall width (asymmetrical width for N: Lower leg length
windswept legs or scoliotic posture
O: Foot Length
Additional Comments:
Hamstring flexibility: Pelvis to thigh angle accommodate greater than 90 Thigh to calf angle accommodate less than 90
Describe Reflexes/tonal influence on body:

7.
COMMENTS:
POSTURE:
Anterior / Posterior Obliquity Rotation-Pelvis
P
E
L
V
I Neutral Posterior WFL R elev l elev WFL Right Left
S Anterior Anterior Anterior
Fixed Other Fixed Other Fixed Other
Partly Flexible Partly Flexible Partly Flexible
Flexible Flexible Flexible
TRUNK Rotation-shoulders and upper
Anterior / Posterior Left Right trunk
Neutral
WFL ↑ Thoracic ↑ WFL Convex
Convex Left-anterior
Lumbar
Kyphosis Left Right-anterior
Lordosis Right
c-curve s-curve
multiple
Fixed Flexible Fixed Flexible Fixed Flexible
Partly Flexible Other Partly Flexible Partly Flexible Other
Other
Describe LE Neurological Influence/Tone:
Position Windswept
Hip Flexion/Extension
Limitations:
H
I
P   
S Neutral Abduc ADduct Neutral Right Left

8.
Fixed Fixed Other
Subluxed Partly Flexible
Partly Flexible
Hip Internal/External
Dislocated Range of motion Limitations:
Flexible Flexible
Knee R.O.M.
Foot Positioning
Left Right WFL L R
KNEES WFL WFL ROM concerns:
& Limitations Dorsi-Flexed L R
Limitations
FEET Plantar Flexed L R
Inversion L R
Eversion L R
COMMENTS:
Posture:
Good Head Control Describe Tone/Movement
HEAD of head and Neck:
Functional
& Flexed Extended Adequate Head Control
Rotated L Lat Flexed Limited Head Control
NECK L
Rotated R at Flexed R
Cervical Hyperextension Absent Head Control
Upper R.O.M. for Upper Describe
Extremity SHOULDERS Extremity Tone/Movement of UE:
WNL
WFL
Limitations:
Left Right
Functional
Functional
elev / dep elev / dep UE Strength Concerns:
pro-retract pro- N/A
retract
None
subluxed subluxed
Concerns:
R.O.M.
ELBOWS
Left Right

9.
Strength concerns:
Left Right Strength / Dexterity:
WRIST
&
Fisting
HAND
Goals for Wheelchair Mobility
Independence with mobility in the home and motor related ADLs (MRADLs) in the community
Independence with MRADLs in the community
Provide dependent mobility
Provide recline
Provide tilt
Goals for Seating system
Optimize pressure distribution
Provide support needed to facilitate function or safety
Provide corrective forces to assist with maintaining or improving posture
Accommodate client’s posture: current seated postures and positions are not flexible or will not tolerate corrective
forces
Client to be independent with relieving pressure in the wheelchair
Enhance physiological function such as breathing, swallowing, digestion
Simulation ideas:
Equipment trials:
State why other equipment was unsuccessful:
SEATING COMPONENT RECOMMENDATIONS AND JUSTIFICATION
Component Manuf/mod/size Justification
Seat Cushion accommodate impaired stabilize pelvis
sensation accommodate obliquity
decubitus ulcers present accommodate multiple
prevent pelvic extension deformity
low maintenance neutralize LE
increase pressure

10.
distribution
Seat Wedge accommodate ROM Provide increased
aggressiveness of seat shape
to decrease sliding down in the
seat
Cover Replacement protect back or seat cushion
Mounting fixed attach seat platform/cushion to mount headrest
hardware w/c frame swing medial thigh
lateral trunk supports swing away for: attach back cushion to w/c support away
headrest frame swing lateral supports
away for transfers
medial thigh support
back seat
 Seat Board support cushion to prevent allows attachment of
 Back Board hammocking cushion to mobility base
Back provide lateral trunk support provide posterior trunk
accommodate deformity support
accommodate or decrease tone provide lumbar/sacral
support
facilitate tone
support trunk in midline
Lateral pelvic/thigh pelvis in neutral accommodate tone
support removable for transfers
accommodate pelvis
position upper legs
Medial Knee decrease adduction remove for transfers
Support accommodate ROM alignment
Foot Support position foot stability
accommodate deformity decrease tone
control position
Ankle strap/heel support foot on foot support provide input to heel
loops decrease extraneous protect foot
movement
Lateral trunk R L decrease lateral trunk leaning safety
Supports accom asymmetry control of tone
contour for increased contact
Anterior chest decrease forward movement of added abdominal
strap, vest, or shoulder support
shoulder retractors accommodation of TLSO alignment
decrease forward movement of assistance with shoulder
trunk control
decrease shoulder
elevation
Component Manuf/mod/size Justification
Headrest provide posterior head support improve respiration

11.
provide posterior neck support placement of switches
provide lateral head support safety
provide anterior head support accommodate ROM
support during tilt and recline accommodate tone
improve feeding improve visual orientation
Neck Support decrease neck rotation decrease forward neck flexion
Upper R L decrease edema decrease gravitational pull on
Extremity decrease subluxation shoulders
Support control tone provide midline positioning
Arm trough provide work surface provide support to increase
Posterior hand UE function
placement for
support AAC/Computer/EADL provide hand support in natural
½ tray position
full tray
swivel mount
Pelvic stabilize tone pad for protection over boney
Positioner decrease falling out of chair/ prominence
Belt **will not decrease potential for prominence comfort
SubASIS bar sliding due to pelvic tilting special pull angle to control
prevent excessive rotation rotation
Dual Pull
Bag or pouch Holds: diapers catheter/hygiene
medicines special food ostomy supplies
orthotics clothing
changes
Other

12.
Recommendations/ Modifications in the W/C:
Signature of the PT