Your Mobility Assessment

Power Chair Quiz

Name

Which conditions affect your mobility?

Multiple sclerosis (MS)

Parkinson's disease

ALS

Stroke

Spinal cord injury

Muscular dystrophy

Cerebral palsy

Myopathy or other muscle disease

Congenital skeletal condition (present from birth)

Other neurological condition

Other / not sure

Which insurance do you have?

Medicare / Medicare Advantage

Medicaid

Private / employer insurance

No insurance / not sure

What do you currently use to get around?

Nothing

Cane / walker

Manual wheelchair

Power wheelchair / scooter

Why isn't your current equipment working for you anymore?

I don't use any equipment

I've fallen or almost fallen

I get too tired / not strong enough

It broke

Which daily activities are hardest right now?

Getting to the bathroom / kitchen

Moving between rooms

Dressing or bathing

Getting in and out of bed or a chair

None of these

May a mobility specialist reach out to you by phone or text?

Yes, please reach out

No, not right now

Phone

Email