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Manual Wheelchair Specification Form - Short Form Questionnaire Version

Information about wheelchair

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Umesh Bhandari
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23 views2 pages

Manual Wheelchair Specification Form - Short Form Questionnaire Version

Information about wheelchair

Uploaded by

Umesh Bhandari
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Manual Wheelchair Specification Form – Short Form Questionnaire Version

(Please tick the open boxes that represent your answers)

Person completing the questionnaire: ______________________________________

Date: ____________________

Questions
1. Labels:
Do you see any stickers or labels anywhere on the frame of the wheelchair?
 Yes (specify): ____________________________________________________
 No
 Unsure
2. Frame type:
Does your chair fold?
 Yes
 No
 Unsure
If yes:
 Does it fold from side-to-side, narrowing it?
 Or does the backrest fold forward onto the seat?
 Unsure
3. Positioning options:
Does your chair tilt? (when your body moves as one as the whole seat rocks back)
 Yes
 No
 Unsure
Does your chair recline? (when your back leans back away from your knees)
 Yes
 No
 Unsure
4. Rear wheels:
Do your rear wheels come off without tools?
 Yes
 No
 Unsure
Does your wheelchair have brakes?
 Yes
 No
 Unsure
5. Cushion:
Does your wheelchair have a cushion?
 Yes
 No
 Unsure

Manual Wheelchair Specification Form – Short Form Questionnaire Version


Version: February 4, 2021
6. Seat belt:
Do you have a seat belt on your wheelchair?
 Yes
 No
 Unsure
7. Backrest:
What is the backrest material?
 Flexible
 Hard material on the back of it with padding in front
 Unsure
8. Push-handles:
Does your wheelchair have handles at the top of the backrest for a caregiver to use?
 Yes
 No
 Unsure
9. Footrests:
Do you have footrests on your wheelchair?
 Yes
 No
 Unsure
If yes, are the footrests on both the left and right sides or just one?
 Both sides
 Right only
 Left only
 Unsure
If yes, can the footrests be moved out of the way or removed?
 Yes
 No
 Unsure
10. Armrests:
Do you have armrests on your wheelchair?
 Yes
 No
 Unsure
If yes, can the armrests be moved out of the way or removed?
 Yes
 No
 Unsure
11. Rear Anti-tip Devices:
Do you have bars or small wheels at the back of your wheelchair that stop the wheelchair from
tipping over backward?
 Yes
 No
 Unsure

Manual Wheelchair Specification Form – Short Form Questionnaire Version


Version: February 4, 2021

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