Mobility Scooter or Powered Wheelchair Assessment Questionnaire

Personal Details

All information provided will be treated as confidential.

Name

First

Last

Date of Birth

Height

Choose to use either metric or imperial measurements

Metric (centimetres)
Imperial (feet and inches)

What is your height in centimetres?

Centimetres (cm)

Other Information

Date of Assessment Booking

Are you naturally right or left handed?

Right
Left

Occupation

Are you employed full-time or part-time?

Are you completing this form yourself?

Name of person completing this form

Relationship to you

For example, a friend, carer or sister.

Your Doctor or Consultant

Name of your doctor or consultant

Address of your doctor or consultant

Phone number of your doctor or consultant

Medical and Health Information (Part 1)

Please answer the following questions in detail, including any information that you feel may be relevant to operating a mobility scooter or powered wheelchair.

Do you suffer from blackouts or sudden attacks of dizziness?

Do you have epileptic fits?

If so, on what date did you have your last fit?

Do you have any hearing problems?

What is your medical condition or disability and when was it diagnosed?

Do you take any medication? If so, please list below.

How does your condition/disability affect you?

Do you experience any pain? (Please give details).

Please write down any additional information which may be relevant to you using a mobility scooter or powered wheelchair in the space provided below.

Medical and Health Information (Part 2)

Please answer YES or NO to the following questions and give details where appropriate.

Do you have any problems with short-term memory?

Do you have any spatial difficulties (judgement of space)?

Do you have any problems with concentration?

Do you have any problems with speech?

Do you have any problems with understanding spoken words or following spoken instructions?

Have you been diagnosed as having Dementia?

Eyesight

When did you last have your eyesight tested?

Do you wear glasses?

Do you wear contact lenses?

Please state when you wear your glasses or contact lenses (reading, TV, driving, full-time, etc.)

Do you think that you can read a current-style number plate in good daylight from a distance of 12.3 metres? (This may be wearing your contact lenses or glasses).

Yes
No
Not sure

Do you have any other eyesight related conditions?

Mobility

Can you walk unaided (without the aid of sticks, crutches, or a care assistant)?

sticks, Do your

How far can you walk unaided?

If you selected 'No', can you walk with the aid of sticks or crutches?

How far can you walk using your aid?

Please give details of any other information that you feel may be relevant to your personal mobility needs.

Your Vehicle

Do you drive a car?

Do you currently own a car?

Will you need to transport your scooter or wheelchair in a car?

What make is your car?

For example 'Volkswagon'.

What model is your car?

For example 'Polo'.

How many passenger doors does your car have?

A Hatchback with two passenger doors is considered to be a 'three door'. Only include passenger doors here.

Does your car belong to you, or is it a Motability vehicle?

I own it
Mobility owned
Other

Your Mobility Scooter or Powered Wheelchair

Where do you plan to store a scooter when it is not in use?

Where do you plan to use scooter or powered wheelchair?

Is there an electrical socket (for charging), close to where scooter will be stored?

Is there level access (no steps) from public pavement to the place where you would wish to store scooter?

Declaration

Herts Ability may, on occasion, feel it appropriate to forward a copy of your assessment report to the agency that referred you and/or your Doctor. Please could you indicate that you are willing for this to happen by signing below?

By signing this form, you also declare that the information provided is true and correct.

Signature

Clear Signature

Date

Herts Ability

Suite 4, Wentworth Lodge
Great North Road
Welwyn Garden City
Hertfordshire
AL8 7SR

Registered charity No. 1059015