Medical Transportation Level of Need Assessment Form
Please complete this assessment to determine the appropriate transportation support for the rider.
Rider Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Trip Purpose
*
Please Select
Medical Appointment
Therapy Session
Treatment
Hospital Discharge
Other
Pick-up Location
*
Destination Location
*
Mobility and Assistance Needs
*
Rows
None
Minimal
Moderate
Extensive
Walking Assistance
1
2
3
4
Standing Support
5
6
7
8
Supervision Required
9
10
11
12
Will the rider require an escort or companion?
*
Yes
No
Wheelchair or Mobility Device Use
*
Manual Wheelchair
Powered Wheelchair
Walker
Cane
None
Does the rider need a lift or ramp for vehicle access?
*
Yes
No
Rate the rider’s difficulty with stairs or transferring to a vehicle
*
1
2
3
4
5
Preferred Transport Level or Accommodation
*
Please Select
Standard Vehicle
Wheelchair Accessible Vehicle
Stretcher Transport
Other
Submit Assessment
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