Assessment Details

Occupational Therapy

Powered Mobility Device Assessment

Client Details

Name

Date of Birth

Phone Number

Email Address

Address

Street addressStreet address line 2

Suburb

StatePlease selectACTNSWNTQLDSATASVICWA

Postcode

CountryPlease selectAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Occupational Therapist Details

Name

Position

Phone Number

Email Address

Assessment Details

Date of Assessment

Referral Source

Reason for Referral

Name of Referrer

Referrer's Email Address

Consent Obtained

Yes - VerbalYes - WrittenNo - VerbalNo - Written

Persons Present for AssessmentDaphne Totten - Occupational Therapist

Purpose of the Assessment

Trial and driving assessment of “X” mobility device. Driving assessment to determine if Xis safe to use the powered mobility device to access the local community including: 

Powered mobility device outcome

Able to use PMDSupervised PMD useNot appropriate at this time - further training requiredNo appropriate to use a PMD

Relevant Medical History

Medication

YesNo

Provide further details

Sedative

YesNo

Provide further details

Vision

ImpairedNormal

Provide further details

Glasses

YesNo

Provide further details

Hearing

ImpairedNormal

Provide further details

Hearing Aids

YesNo

Provide further details

Falls History

Medical Conditions

Summary of Body Functions & Structures

Summary of Body Functions & Structures

Cognition

Upper Limb Function

Lower Limb Function

Sacral Skin Integrity

IntactRednessOpenScar Tissue

Description

Does the client use a pressure cushion?

YesNoUnsure

Provide further details

Is a pressure cushion required?

YesNoUnsure

Please specify

Basic Road Craft

Basic Road Craft

The client was provided with the below information and then asked to recall answers - they were able to answer all questions correctly during the assessment.

Are PMD users considered motorists or pedestrians?

At what speed should a PMD be driven?

Where should a PMD be used or driven?

What position on the footpath should a PMD maintain?

If you travel on the road, should you be facing the traffic, or should it be behind you?

When approaching a road, what are three things you will need to consider before crossing?

In what position should the PMD be, prior to crossing a kerb?

Can you identify three potential problems or obstacles you may face on a footpath?

How can you make yourself visible to other pedestrians and drivers?

Practical & Overall Considerations

Practical and Overall Considerations

Is this the initial assessment?

YesNo

Please specify how many assessments there have been

Location of the assessment?

ResidenceCommunityIndoorsOutdoorsShopsOther

Please specify location

Is the participant able to sit with stability and reach the controls?

YesNo

Provide further details

Is the participant able to manipulate the controls?

YesNo

Provide further details

Is the participant positioned optimally in the PMD?

YesNo

Provide further details

Is the participant's sitting tolerance adequate for assessment and intended use?

YesNo

Provide further details

Management of Mobility Device

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Can the participant manage the following with their mobility device?

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Location

Footpaths

YesNo

Provide further details

Mounting curbs

YesNo

Provide further details

Crossing roads/intersections

YesNo

Provide further details

Crossing at traffic lights

YesNo

Provide further details

Select safe place to cross

YesNo

Provide further details

Observe road rules

YesNo

Provide further details

Remain safe around pedestrians

YesNo

Provide further details

Obstacles

YesNo

Provide further details

Uneven terrain

YesNo

Provide further details

Ramps

YesNo

Provide further details

Slopes

YesNo

Provide further details

Board (use and exit public transport)

YesNo

Provide further details

Respond to unexpected events

YesNo

Provide further details

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Mobility Device

Use the breaks or speed controls

YesNo

Provide further details

Use indicators

YesNo

Provide further details

Check the battery level

YesNo

Provide further details

Turn on and off the device

YesNo

Provide further details

Charge or instruct others to charge

YesNo

Provide further details

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Safety

Judge space and distance

YesNo

Provide further details

Appropriate reaction times

YesNo

Provide further details

Remain non-distracted

YesNo

Provide further details

Use horn appropriately

YesNo

Provide further details

Maintain appropriate behaviour

YesNo

Provide further details

Turn head or trunk to scan

YesNo

Provide further details

U-turns

YesNo

Provide further details

3 Point Turns

YesNo

Provide further details

Reverse safely

YesNo

Provide further details

Results & Recommendations

Results & Recommendations

Does the participant require further training?

YesNo

What further training is required?

RecommendationComprehensive education was provided regarding safe operation, speed control, hazard awareness, environmental scanning, braking, manoeuvring, and safe negotiation of footpaths, kerbs and community environments. The client was instructed on safe charging practices, appropriate storage, regular maintenance requirements, and the need to adhere to manufacturer guidelines. Ongoing safe use, maintenance, and compliance with road/footpath regulations remain the responsibility of the client and/or their carers. The OT’s role is limited to assessment, prescription and education at the time of issue, and the client was advised to discontinue use and seek reassessment if any changes occur that may impact safety. Regular annual reassessment is recommended.

Recommendation

Actions

Occupational Therapist Signature

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Occupational Therapist Name

Date of Occupational Therapist Signing

This is the final copy of the assessment and will be sent to the referrer email address

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