Wheelchair Usage Assessment Checklist
Please complete the checklist to assess wheelchair usage and safety.
User Identification
Full Name of User
First Name
Last Name
Date of Assessment
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Wheelchair Type
Manual
Electric
Other
Usage Frequency
Daily
Several times a week
Weekly
Occasionally
Rarely
Environment of Use
Indoors
Outdoors
Both
Safety and Comfort Checks
Does the wheelchair fit the user properly?
Yes
No
Are all wheelchair brakes functioning properly?
Yes
No
Is the wheelchair clean and well-maintained?
Yes
No
Are cushions and supports adequate for comfort?
Yes
No
Are there any visible damages or wear?
Yes
No
Additional Comments
Submit
Should be Empty: