Als Society Of Bc Assistive Equipment Prescription Form (Page 2 of 4) in pdf

ALS Society of BC—Assistive Equipment Prescription Form

Client’s Surname: ________________________

Mobility Aids



Cane __________ handle height (select one) Quad Cane Regular Cane



Folding Stationary Walker ___________ Handle height



2 Wheeled Walker ___________ Handle height



4 Wheeled Walker ___________ Handle height

________________ Seat height

Manual Wheelchairs & Scooters



Transport Wheelchair (select one) 17 inches

19 inches



Scooter (select one) 3 wheeled portable 3 wheeled non-portable

4 wheeled



Manual Wheelchair - __________ (width) x __________ (depth) ______________ Seat to floor without cushion



Manual Tilt Wheelchair - __________ (width) x __________ (depth)

Back Height: _________________ inches

Seat to Floor Measurement (without cushion): _________________ inches

Power Wheelchairs

*please note the below information assists the Society in providing the closest available match to your request. Exact brands may not be

available.



Power wheelchair

 With Tilt  Without Tilt

Seat Width: _________________ inches

Seat Depth: _________________ inches

Back Height: _________________ inches

Seat to Floor Measurement (without cushion): _________________ inches

Drive Preference: Mid-Wheel Drive Rear-Wheel Drive

Control: (select all that apply)Right Side

Left Side

Attendant Control

Control Type: Joystick

 Goalpost

Cushions

Wheelchair Options

__________ (width) x __________ (depth)



Gel ROHO High Profile

Seatbelt

 Anti-Tippers



Foam basic ROHO Low– Profile

Full Lap tray

1/2 Lap Tray (circle one) Left/Right

___________________________ Preferred Brand



Headrest Specifications:________________________________________



Footrests: (select one) Platform Elevating Swing-away



Backrest contour: (select one) Mild  Moderate Aggressive

1233—13351 Commerce Parkway, Richmond BC PH 604-278-2257 OR 1-800-708-3228 FAX 604-278-4257

Email: equipmentloan@alsbc.ca Website:

CHARITABLE REGISTRATION # 10670 8985 RR0001

Page 2 of 4

Als Society Of Bc Assistive Equipment Prescription Form Page 2

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