Wheel Chair or Equipment Evaluation Form Clinic Location Child has appointment scheduled at* Pooler Richmond Hill Patient’s name* Caregiver’s name* Phone number*Primary Language Patient 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):* Δ