Wheelchair Assessment Pricing Form

First name*

Last name*

Phone

Is the health condition progressive and/or does symptom severity fluctuate?

Yes

Any cognitive or visual impairments?

Yes

Currently walking independently (with or without aids, for example cane or walker), even for short distances only? If assistance for walking is required, please select “no”.

Yes

Is the wheelchair needed for interim use/community use only? For example, going out to restaurant with family or medical appointments etc.

Yes

Currently using a wheelchair as primary method of mobility?

Yes

If yes, select all that apply:

The wheelchair is manual

The wheelchair is power

The wheelchair has a tilt function

Spending over 6 hours a day in the wheelchair or other seated surface (for example lift chair recliner)

Able to move the wheelchair around independently within the home

Able to move the wheelchair around independently in outdoor terrain and long distances

Able to transfer from the wheelchair to a vehicle seat independently

Able to adjust body position in the wheelchair independently

Has skin breakdown or wounds

Only seating components (e.g. backrest cushion) updates required and no updates to the wheelchair itself

Please select a level of documentation you would like to receive with this service (select one)

None

Brief Letter/Email

Comprehensive Report

Thank you! Once we have received your pricing form, you will receive a call within 2 business days. You will then be provided with pricing and intake information. If you are interested in proceeding, our OTs typically can book an assessment within 2 weeks of receiving the completed intake forms.

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1431 Corydon Avenue

Winnipeg, Manitoba, Canada

R3N 0J2

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Wheelchair Assessment Pricing Form

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