Patient:

Sex:
DOB:

Age:

Address:


ITEM ORDERED


Date of face-to-face examination:

Date of order:

Start date:

Length of need: 99 months

DIAGNOSES



USE


OPTIONS


HISTORY

Historian:
Time condition(s) present:

Setting:
Maximum distance ambulated independently:
Falls:
Pressure sores:

AMBULATION
Cane:
Walker:
Manual wheelchair:

Progression of ambulation difficulty over time:

Able to use power operated vehicle (scooter):

ACTIVITIES OF DAILY LIVING
Reports limited activities of daily living d/t:

ADLs requiring assistance of staff:


PHYSICAL EXAM
Weight:

Height:

Resting pulse:

Exertional pulse:

Blood pressure:

Respirations:

Oxygen saturation:


Posture:

Tremor:
Vision:
Hearing:
Cognition:
Neck:
UE:

LE:

Trunk:

Sit to stand:
Gait:

Skin:


NARRATIVE
This is a
yo patient with several health problems worsening gradually over the past year despite use of multiple medications. Can no longer perform independently the majority of ADLs without significant SOB and overall discomfort. Reports doorways and halls are wide enough for a scooter that will allow access to shower, toilet, sink and dining room. Possesses physical and mental abilities to safely operate a power mobility device. Willing and motivated to use a power mobility device.

CERTIFICATION
I certify that the information provided is a true and accurate representation of my patient’s current condition and that a major reason for the visit was a mobility examination. I hereby incorporate this document into my patient's medical record.

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