Scribd Logo
Upload

Welcome to Scribd!

  • Wheelchair Measurement Form

    Uploaded by

    Nick Halden
    36 views2 pages
    form for wheelchair

    Original Title

    wheelchair measurement form

    Copyright

    © © All Rights Reserved

    Available Formats

    XLSX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    form for wheelchair

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    36 views2 pages

    Wheelchair Measurement Form

    Uploaded by

    Nick Halden
    form for wheelchair

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    WHEELCHAIR PRESCRIPTION FORM DATE :

    Name : A/S No. :

    I/C : Diagnostic :

    Age : Prescription :

    Sex : Estimated Price :

    Tel. No : Funded By :

    Remarks :

    Customized System
    Extended Handle

    Handle Brake

    Head Support /
    Neck Support
    Solid Back /
    Double Back Support
    Lateral Support

    Butterfly / H - Strap

    Body Strap

    Pelvic Support

    Pommel

    User Brake

    Lap Tray / Table Top

    Foot Strap
    Date PIC's Sign Patient's Sign
    Foot Box Fitting 1
    Fitting 2

    Fitting 3

    You might also like