E QUIPMENT PROGRAM ELECTRIC RECLINER LIFT CHAIR ASSESSMENT FORM

PUBLIC SCHOOLS DOCUMENTATION FOR USE OF THERAPEUTIC EQUIPMENT
090113 202T161 REMOVAL OF EXISTING TRAFFIC SIGNAL EQUIPMENT
11 LEC2 دعبد المنعم الخفاجي INSTRUMENTS AND EQUIPMENT FOR

113006 REMOVAL OF EXISTING TRAFFIC SIGNAL EQUIPMENT THE FOLLOWING
1212014 APPLICANT’S NAME SYSTEMS AND EQUIPMENT (ELECTRICAL EQUIPMENT) SEE
12172019 SIMPLE HARMONIC MOTION PENDULUM EQUIPMENT NEEDED DELL LAPTOP

Equipment Prescription Form LSA

EE QUIPMENT PROGRAM ELECTRIC RECLINER LIFT CHAIR ASSESSMENT FORM quipment Program

Electric recliner lift chair assessment form

Complete eligibility screen before proceeding with this prescription

Client name:

     

Sex: M F

Other

     

DOB:

     

Address:

     

Phone No:

     

Clinician:

     

Division:

     

Date:

     

People consulted:

     

Medical History

Diagnosis/Prognosis:

     



Pain:

     

Height:

     

Weight:

     


Sensation: (note areas that are abnormal or insensate)

     



Skin history/integrity:

     



Pressure relief: Independent Assisted

Methods used:

     



Cushions:

     

Bladder: Continent Incontinent

Management:

     



Bowel: Continent Incontinent

Management:

     




Social History

Environment (note space for chair, other furniture, access to power point, floor surface etc.)

     



Activity configuration (note time spent in chair, activities to be done in chair etc)



     






Current chair(s) used:

     




Other options available at home:

     






Transfers/ Mobility


Ambulation status:      


Transfer onto chair:      


Transfer off chair:      


Weight shifting in chair:      


Carer needs in assisting Client:      


Basic dimensions:


Height:      _____ Weight:      _____ A: Seat-elbow      ____ B: Back of knee-heel      _____


C: Posterior of buttocks-back of knee      _____ D: Widest point at hips or thighs      _____


E QUIPMENT PROGRAM ELECTRIC RECLINER LIFT CHAIR ASSESSMENT FORM

Options for Chair

Control: Left Right

Customisation needed Yes No Details:     

Fabric preference: (vinyl, dartex, synergy, cloth, colour etc.)      

Incontinence covers required Yes No

Armrest covers: Yes No

Wall-saver function required Yes No Justification:      

Dual motor required: Yes No Justification:      


Client Goals And Concerns

     





Additional Notes/Summary

     









Short Term Plan(s):

Trial equipment :

     



Date/Place:

     



Obtain further info

     



Other

     




Info given to client:

Terms and Conditions

‘Preventing Pressure Sores’ pamphlet as indicated

Other:      





Clinician Name:

     

Clinician Signature:


Date

     


Phone: 1300 295 786 Ɩ Fax: 1300 295 839 Ɩ Web: www.des.sa.gov.au Page 3 of 3

Equipment Program – Electric Recliner lift chair assessment form | 21 September 2016

The information printed in this document is only accurate as of the displayed print date 16-10-2021 3:07:03 AM. The South Australian Department for Communities and Social Inclusion does not accept any liability for misinformation, injury, loss or damage incurred by use of or reliance on the information provided in this print copy. Date for Review: 21/9/2019


1EQUIPMENT BROUGHT BY THE USERS DESCRIPTIONNAME 2HAS BEEN
2011 CHEVROLET VOLT STANDARD & AVAILABLE EQUIPMENT DESCRIPTION S
230513P---Motor-Requirements-for-HVAC-Equipment-03-07-2022


Tags: assessment form, chair assessment, program, quipment, chair, assessment, electric, recliner