Power Wheelchair Assessment Checklist Form
Complete this checklist to assess power wheelchair needs and fit. This form uses a clean, premium SaaS design for an elegant and approachable experience.
Primary Reason for Assessment
*
Initial wheelchair selection
Wheelchair replacement
Fit or comfort concerns
Other
Areas of Mobility to Support (select all that apply)
*
Indoor mobility
Outdoor mobility
Community access
School/work use
Other
Current Wheelchair Fit and Comfort
Rows
Poor
Fair
Good
Excellent
Seat width
1
2
3
4
Seat depth
5
6
7
8
Back support
9
10
11
12
Cushioning
13
14
15
16
Foot support
17
18
19
20
Control Method Preferences
Standard joystick
Head array
Sip-and-puff
Switch controls
Other
Environmental Considerations
Narrow doorways
Uneven terrain
Steep ramps
Public transport use
Other
Postural Support Needs
Lateral trunk supports
Headrest
Tilt/recline
Elevating leg rests
Other
Safety Features Desired
Seat belt
Anti-tip wheels
Lights/reflectors
Horn
Other
Overall Power Wheelchair Suitability
1
2
3
4
5
Additional Notes or Recommendations
Submit Assessment
Should be Empty: