Manual Wheelchair Pre-Assessment Form

All information on this form is encrypted and sent securely using a SSL certification. A secure SSL connection protects you online when providing information to our company such as filling out forms such as these and making transactions.

Therapist Details

Client Information

Funding Source

Client Diagnosis

Manual Wheelchair Requirements

Client Measurements

Please provide as much anthropometric data as possible, as it helps to set up the chair for demonstration prior to the appointment.

Please enter measurements in either cm's or inches

A Top of Shoulders

B Chest Depth

C Chest Width

D Seat Depth

E Top of Head

F Elbow to Hand

G Seat Surface to Elbow

H Hip Width

I Knee to Floor

Seating Requirements