ADP Assessment Express Form
ADP Assessment Express Form
Measurements
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Rollator
Wheelchair
Powerchair
Rollator Assessment
ROLLATOR ASSESSMENT
Rollator Type
Type 1
Type 2
Type 3
Handle Height
Inch
Seat Height
Inch
Choose Addons
Curb Climber
Cane Holder
Cup Holder
Slow Down Brakes
Footrest
Wheelchair Assessment
WHEELCHAIR ASSESSMENT
Wheelchair Type
*
Type 1 – Adult Standard Manual Wheelchair
Type 2 – Adult Lightweight Standard Manual Wheelchair
Type 3 – Adult Lightweight Performance Manual Wheelchair
Type 4 – Adult High Performance Rigid Manual Wheelchair
Type 5 – Adult Manual Dynamic Tilt Wheelchair
Powerchair Type
*
Adult Power Base Type 1
Adult Power Base Type 2
Adult Power Base Type 3
Seat Width (Inches)
*
Inch
Seat Depth (Inches)
*
Inch
Legrest Length (Inches)
*
Inch
Seat to Floor Height (Inches)
*
Inch
Cane Height (floor to handle) (Inches)
*
Inch
Back Height (Inches)
*
Inch
Frame Options – ADP Funded Options (Rationale Required for these options)
Recliner Option
Dynamic Tilt Frame
Titanium Frame
Wheel Options/Addons – ADP Funded Options
Caster Pin Locks (pair)
Spoke Protectors (pair)
Amputee Axle Plates (pair)
Quick Release Axles (pair)
Uni-Lateral Wheel Lock
One Arm/Lever Drive
Plastic Coated Handrims
Projected Handrims (pair)
Grade Aids (pair)
Legrest Accessories – ADP Funded Options
Angle Adjustable Footplates
Elevating Legrests (pair)
Legrest Padding – Foot/Leg Support Options (Modular)
Footrest Padding – Foot/Leg Support Options (Custom)
Calf Panel – Foot/Leg Support (Modular)
Calf Panel (Custom) – Foot/Leg Support (Custom)
Flip Forward Calf Panel – Foot/Leg Support (Custom)
Additional ADP Funded Options
Adjustable Tension Back Upholstery
Heavy Duty Cross Braces & Upholstery
Stroller Handles/Paediatric
Oxygen Tank Holder
Ventilator Tray
Seat Belt Type – ADP Funded Options
Standard Belt – No Padding
Padded Belt – Positioning Belts (Modular)
4 Point Seat Belt – Positioning Belts (Modular)
Chest Harness – Positioning Belts (Modular)
Additional Pads – Positioning Belts (Custom)
Powerchair – Additional ADP Funded Options
Adjustable Tension Back Upholstery
Midline Control
Manual Recline Option
Angle Adjustable Footplates (pair)
Manual Elevating Legrests (pair)
Swingaway Mounting Bracket – Required**
One Piece 90/90 Front Riggings – Required**
Seat Package 1 for Power Bases – Required**
Seat Package 2 for Power Bases
Oxygen Tank Holder
Ventilator Tray
Specialty Components (Rationale Required for these options)
Specialty Controls 1 Non Standard Joystick
Specialty Controls 2 Chin/Rim Control
Specialty Controls 3 Simple Touch
Specialty Controls 4 Proximity Control
Specialty Controls 5 Breath Control
Specialty Controls 6 Scanners
Auto Correction System
Additional Information/Customization
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