Online Scooter Evaluation Template

Scooter Assessment
Patient's scooter experience: The patient, Mr. John Smith, has been utilizing a scooter for the past 3 years. He reports a high level of comfort but occasionally encounters challenges with maneuvering in confined spaces.
Previous funding information: Mr. Smith previously obtained funding from the National Mobility Aid Program in 2022 for a manual wheelchair.
Mobility aid usage: Currently, Mr. Smith employs a cane for short distances and a manual wheelchair for longer distances. He finds the cane effective for stability but requires the wheelchair for endurance.
Government funding requirements: Mr. Smith qualifies for government funding due to his diagnosed mobility impairment and limited walking capacity.
Living environment: Mr. Smith resides in a single-story home with ample space for scooter storage and accessible pathways.
Building accessibility: The building features a ramp and wide entrance, but lacks an elevator, which is unnecessary for his single-story home.
Medical history: Mr. Smith has a history of osteoarthritis and peripheral neuropathy, affecting his mobility.
Diagnoses: Osteoarthritis and peripheral neuropathy.
Symptoms: Mr. Smith experiences joint pain and muscle weakness, impacting his mobility.
Medications: He is on medication for pain management, which may affect his alertness.
Physical assessment: The assessment indicated reduced muscle strength in the lower limbs and moderate balance issues.
Walking ability: Mr. Smith can walk short distances with a cane but has limited endurance and stability.
Scooter test drive: During the test drive, Mr. Smith demonstrated good maneuverability and safety awareness, with minor difficulties in tight turns.
Fall history: Mr. Smith has experienced two falls in the past year, attributed to balance issues.
Current scooter condition: His current scooter shows signs of wear and requires minor repairs.
Scooter upgrade preferences: Mr. Smith desires a scooter with enhanced seating comfort and improved speed control.
Mobility with walker: Mr. Smith finds using a walker challenging due to balance issues.
Patient information: 
- Health card number: 123456789
- Date of birth: 1950-06-15
- Full name: John Smith
- Weight: 85 kg
Funding application process: The application requires a medical assessment report and proof of income, with an expected processing time of 6-8 weeks.
Estimated processing time: 6-8 weeks.
Additional patient comments: Mr. Smith expressed concern about the funding timeline affecting his mobility.
Importance of scooter to patient: A new scooter would significantly enhance Mr. Smith's independence and quality of life, allowing him to engage more in community activities.
Closing remarks: It is recommended that Mr. Smith proceed with the funding application for a new scooter with the desired features.
Next steps: Follow-up with Mr. Smith in 4 weeks to check on the progress of the funding application and address any further needs.