3801 Lake Otis Pkwy., Ste.

100
Anchorage, AK 99508
(907) 212-2948
(907) 212-6310 Fax

WHEELCHAIR AND SEATING CLINIC

REFERRAL FORM

REFERRAL SOURCE
Name: Phone:
Agency: Fax:
Address:

PATIENT INFORMATION
Name: Guardian/Caregiver:
Address: Date of Birth:
Primary Diagnosis:
Day Phone: Secondary Diagnosis:
Evening/Alternate Phone: Height: Weight:
Primary Physician:

INSURANCE INFORMATION
Medicare #: Private Insurance:
Medicaid #:
Preferred Provider Network/Tricare Yes__ No__
PCP: Phone:

SERVICE REQUESTED/PRIMARY CONCERN:

 Manual Wheelchair Evaluation  Seating System Evaluation  Other:____________________

 Power Wheelchair Evaluation  Scooter Evaluation

CURRENT SERVICES:
DME
Vendor
PT
OT
SP
MD
Other

MOTOR FUNCTION:
Hand Dominance  Right  Left
Right Arm/Hand Function  Full  Partial  Nonfunctional
Left Arm/Hand Function  Full  Partial  Nonfunctional
Lower Extremity Function  Full  Partial  Nonfunctional
Head/Neck Control  Full  Partial  Nonfunctional

MOBILITY:

 Wheelchair  Ambulation Independence

(See Next Section)  Without Device  Cane/Crutch  Independent  Dependent
 Walker  Brace ___________  Assistance Required
Distance:  <10 Feet Safety:  Safe Fall History: Yes__ No__
 10-150 Feet  Unsafe
 >150 Feet
WHEELCHAIR:
 MANUAL Brand:_____________________  POWER / SCOOTER Brand:______________________
Method of Propulsion Level of Assistance Mode of Operation Level of Assistance
 Arms  Legs  Independent  Right Joystick  Head Control  Independent
 1Arm/1Leg  Other  Assist Needed  Left Joystick  Other  Assist Needed
 Dependent  Thumbs / tiller  Dependent

Rough Measurements Condition Age Fit

Seat Width: _______”  Good  Poor  <1 Year  3-5 Years  Too Big  Okay
Seat Depth: _______”  Fair  Inoperable  1-3 Years  >5 Years  Too Small
Specific problems :

SEATING AND POSITIONING:

Sitting Duration Able to relieve pressure Yes__ No__ Method
 <1 Hour  3-5 Hours  >10 Hours  Weight Shift  Manual Recline  Manual Tilt
 1-3 Hours  5-10 Hours   Push-up  Manual Tilt  Power Tilt
Skin Problems Yes__ No__
 Rash  Open Sores
 Redness  Scapes / Bruises
Surgery for skin breakdown Yes__ No__
Location: Date: Facility/Surgeon:

SEATING COMPONENTS

Cushion Type: Condition: Problems:

Back Type: Condition: Problems:
Other Type: Condition: Problems:

EDUCATION/VOCATION:
Grade Completed________________ Special Education? Yes___ No___
Occupation Employer: Job/Duties:
Accessibility/Sitting tolerance concerns:
VISION:
Glasses Worn? Yes__ No__ Bifocals? Yes__ No__ Double Vision? Yes__ No__
Date of Last Exam:
COGNITION:
Difficulty following Yes__ No__
directions
Difficulty with memory Yes__ No__
Districtible Yes__ No__

Does the patient use any other type of adaptive equipment or assistive technology (i.e. splints, communication device, computer, etc.)?
____________________________________________________________________________________________________________

Do you anticipate any future changes in patient’s condition (i.e. planned surgeries, new braces or wheelchair coming,etc.)?
____________________________________________________________________________________________________________

Thank you for referring your patient to The Wheelchair and Seating Clinic at Providence, and for providing
this valuable information. We will be contacting the patient shortly for scheduling. Please remind your
patient to bring any pertinent, currently used equipment.
Please fax completed form to (907) 212-6310

Completed By: ____________________________________________________ Date: _________________