Wheelchair Seating Assessment Questionnaire
Wheelchair Seating Assessment Questionnaire
How would you rate your overall comfort in your current wheelchair seating?
*
1
2
3
4
5
How well does your current seating support your posture?
*
Poor support
1
2
3
4
Excellent support
5
1 is Poor support, 5 is Excellent support
Do you experience any pain or discomfort when seated in your wheelchair?
*
Never
Rarely
Sometimes
Often
Always
Which areas do you feel discomfort or pressure? (Select all that apply)
*
Lower back
Hips
Thighs
Shoulders
Neck
Other
How easy is it for you to transfer in and out of your wheelchair?
*
Very difficult
1
2
3
4
Very easy
5
1 is Very difficult, 5 is Very easy
Please rate the following aspects of your current seating system:
*
Rows
Poor
Fair
Good
Very Good
Excellent
Seat cushion support
1
2
3
4
5
Back support
6
7
8
9
10
Ease of adjustment
11
12
13
14
15
Pressure relief
16
17
18
19
20
How many hours per day do you typically spend in your wheelchair?
*
Please Select
Less than 2 hours
2–4 hours
4–8 hours
More than 8 hours
Do you use any additional support accessories? (e.g., lateral supports, headrest, harness)
*
Yes
No
How would you describe your ability to self-propel or move the wheelchair independently?
*
Fully independent
Mostly independent
Requires some assistance
Requires full assistance
Please describe any specific goals or concerns you have regarding your wheelchair seating.
*
Submit Assessment
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