Wheel Chair or Equipment Evaluation Form Δ Clinic Location Child has appointment scheduled at* Pooler Patient’s name*Caregiver’s name*Phone number*Primary LanguagePatient goals for new equipment*Caregiver goals for new equipment*DiagnosesSurgeriesOrthotics/ProstheticsMedicationsCurrent Seating/Mobility System*Age of system*Is the chair going to be used in the home?* Yes No Is the entrance:*Select one Level Stairs Ramp Lift Width of entrance*Number of floors*Is bedroom accessible?* Yes No Is bathroom accessible?* Yes No Is the child going to be transported in the chair via Van or Bus?* Yes No Does the wheelchair need to be folded down to fit in a car trunk?* Yes No Size of trunk (W x D x H):*