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Wheelchair Assessment Form

Wheelchair Assessment Form

Please complete form below and submit it, we will then be able to confirm the suitability of the vehicle for your needs

Your Contact Details:

Please complete the following wheelchair assessment form as accurately as possible with the wheelchair user seated in their normal relaxed posture. Please note : Overstating dimensions is counter-productive so please take care. Thank you

Measurements:

Please enter all measurements in millimetres (mm) please

Lengths:
From the tip of the toe to the rearmost part of the wheelchair (typically 700 to 1400 mm)
From the front edge of the front wheel to the rearmost edge of the back wheel (typically 600 to 1200 mm)
From the tip of the toe to the rearmost edge of the back wheel (may be the same as (A))
Any other points to note?
Heights:

Note: If the wheelchair has a rise and fall facility please ensure that measurements are taken with the wheelchair in its lowest normal postion

From the floor to the top of the head (typically 1000 to 1400 mm)
From the floor to the eye-line (should be less than D)
From the floor to the lowest part of the foot pedestal i.e. ground clearance (typically from 50 to 400 mm)
From the floor to the wheelchair seat level (typically from 500 to 800 mm)
From the floor to the top of the knee (should be higher than G)
(if the wheelchair has handles) from the floor to the bottom edge of the handles, leave blank if not
Any other points to note?
Widths:
From the outer edges of the left to right rear wheels (typically from 580 to 750 mm)
From the outer edges of the left to right front wheels
Please measure the width from outer edeg to edge
Any other points to note?

About the wheelchair and occupant:

Please tell us the make & model of the wheelchair (if you know them) or leave blank if not
please tell us the approximate weight of the wheelchair (if you know it) or leave blank if not
How heavy is the wheelchair user (approx) kg or stones (please state) eg. 80kg or 13.5 stones

About the carer:

Please let us know any other important points
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