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Wheelchair Assessment Form
Please complete and submit the simple form below to tell us about the wheelchair and occupant.
Today's date
Your full name
(please confirm your full name) e.g. Mr Robert Jones
Your phone number
(please confirm your best contact phone number)
Your email address
For the attention of ?
please select
General enquiry
Ron Smith
David Wagstaff
Darren Morgan
Joe Geary
(please select a recipient for this enquiry)
About the wheelchair & occupant
Is the wheelchair powered or manual?
please select
Manually propelled wheelchair
Powered wheelchair
(please select whether the wheelchair is powered or manually propelled)
Wheelchair + occupant overall length (in millimetres mm)
(please confirm the overall length from the rearmost point of the wheelchair to the tip of the toes of the wheelchair occupant) typically 800 to 1400 (numbers only please)
Wheelchair + occupant, seated height (in millimetres mm)
(please enter the relaxed seated height of the wheelchair occupant) typically 900 to 1600 (numbers only please)
Wheelchair low level overall width (in millimetres mm)
(please enter the overall low level width of the wheelchair) typically 500 to 800
Clearance height of the foot pedestals (in millimetres mm)
(please confirm the maximum ground clearance of the foot pedestals) typically 60 to 300 (numbers only please)
Can the wheelchair occupant bend their head forward when initially accessing the vehicle?
please select
No, the wheelchair occupant cannot bend their head forward
Yes, by about 50 mm
Yes, by about 100 mm
Yes, by about 150 or more
Yes, but there is a headrest on the wheelchair
(please confirm whether the wheelchair occupant can bend their head forward when initially entering the vehicle at the access point)
Comments
(please let us know any other relevant information)
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