Power Mobility Device Evaluation Form Page 3
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6Power Mobility Device Evaluation
Patient’s Name: __________________________
Medications
(List all medications the patient is currently taking relating to the need of a power mobility device)
Medication
Date Started
Dosage
History of Present Problem
1. Functional Ambulatory Limitations
(Complete all limitations that apply)
Shuffling
Normal
Ataxic
Gait/Walk Pattern
Non‐Ambulatory
Mod. Assist
Max. Assist
Limitation
Onset
Description
Diagnosis
Balance/History or Risk of
Falls
Fatigue/Weakness
Inability to Ambulate
Other: _______________
2. Physical Limitations
(Check all limitations that apply and describe all non‐normal findings)
Upper Body Weakness
Mild
Moderate
Severe
(Describe)
(Describe)
____________________________
__________________________
Upper Body Pain
Mild
Moderate
Severe
(Describe)
(Describe)
____________________________
__________________________
Upper Body Range of
Normal
Partially Limited
Severely Limited
(Describe)
(Describe)
Motion
____________________________
__________________________
Lower Body Weakness
Mild
Moderate
Severe
(Describe)
(Describe)
____________________________
__________________________
Lower Body Pain
Mild
Moderate
Severe
(Describe)
(Describe)
____________________________
__________________________
Lower Body Range of
Normal
Partially Limited
Severely Limited
(Describe)
(Describe)
Motion
____________________________
__________________________
The Texas Academy of Family Physicians has created this form and made it available for physicians’ use. It is available on their website at
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