ADP Assessment Form
ADP Assessment Form
Assessment
Accessibility
Biographic Information
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Equipment Needed
Choose Equipment
*
Rollator
Manual Wheelchair
Power Wheelchair
Mobility Scooter
Rollator Assessment
ROLLATOR ASSESSMENT
Rollator Type
Type 1
Type 2
Type 3
Handle Height
Inch
Seat Height
Inch
Choose Basket
Open
Closed
Steel
Choose Addons
Curb Climber
Cane Holder
Cup Holder
Slow Down Brakes
Footrest
Manual Wheelchair Assessment
WHEELCHAIR ASSESSMENT
Wheelchair Type
*
Type 1
Type 2
Type 3
Type 4
Type 5
Seat Width (Inches)
*
Inch
Seat Depth (Inches)
*
Inch
Front Seat Height (Inches)
*
Inch
Rear Seat Height (Inches)
Inch
WHEELS & CASTERS
Frame Options – Addons
Recliner Option
Standard Manual Wheelchair Frame with Manual Dynamic Tilt
Titanium Frame
Wheel Type
Composite
Spoke
Handrims Type
Standard
Plastic Coated
Elongated
Wheel Size
12"
14"
18"
20"
22"
24
INCH
Casters Size
3"
4"
5"
6"
7"
8"
Wheel Lock Type
Push to Lock
Pull to Lock
Left Unilateral
Right Unilateral
Attendant
BACK CANES
Cane Types
Standard
Stroller Bar
Wheel Options/Addons
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)
Cane Options
Angle Adjust
Flip Forward
Cane Height (floor to handle)
*
ARM REST
Arm Rest Type
Standard
Dual Post
Flip Back
Arm Rest Length
Desk Length 10"
Medium Length 12"
Full Length 14"
Extra Large 16"
Canes Options/Addons
Stroller Handles/Paediatric
Oxygen Tank Holder
Ventilator Tray
Arm Pads Materials
Standard Vinyl
Extra Wide Gel Armrest
Additional Gel Pads
LEG REST
Left Legrest
60°
70° (Standard)
80°
90°
Elevating
Residual Limb Support
Right Legrest
60°
70° (Standard)
80°
90°
Elevating
Residual Limb Support
Left Legrest Length
*
Right Legrest Length
*
Armrest Addons
Clothing Guards (pair)
Legrest Customization
N/A
Footplates Type
Composite Standard
Composite Angle Adjustable
Aluminum Angle Adjustable
Legrest Accessories
Elevating Legrests (pair)
Legrest Padding
Footrest Padding
Calf Panel
Flip Forward Calf Panel
Heel Loop
BACKREST
Choose Backrest
*
Back Width (Inches)
*
Back Height (Inches)
*
Additional Information/Customization
CUSHION
Choose Cushion
*
Cushion Width (Inches)
*
Cushion Depth (Inches)
*
ADP Approved Addons
Adjustable Tension Back Upholstery
Heavy Duty Cross Braces & Upholstery
Additional Information/Customization
Seat Belt Type
Standard Belt
Padded Belt
4 Point Seat Belt over Hip
4 Point Belt over Neck
Chest Harness
Any Custom Modifications
Do you need Headrest?
Yes
No
Headrest
HEAD REST
Headrest Type
Straight
Curved
Winged
Headrest Size
Small
Medium
Large
Extra Large
Headrest Hardware
2 Axis
Multi-Axis
Headrest Modifications
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