Vehicle and passenger access assessment form

Your title: *

Mr

Miss

Mrs

Ms

Other

Please select the support, advice or service we can help you with:

Vehicle access

Wheelchair loading

Regaining independence after illness

Advice on what’s available to help me maintain an active lifestyle

Referred by the Motability or other charity

Other

Can you weight bear?

Yes

No

Can you walk unaided?

Yes

No

Do you ever use a wheelchair or scooter either at home or out of doors?

Yes

No

Do you qualify for the Motability Scheme?

Yes

No

What type of problems are you experiencing? Please tick more than one if appropriate:

Getting in or out of the vehicle as a driver

Getting in or out of the vehicle as a passenger

Loading a self-propelled or attendant propelled, manual wheelchair

Loading an electrically powered wheelchair

Loading a scooter

If applicable, please tick where are you accessing your vehicle?

Drive

Roadside

Other

Referring professional’s title (if applicable):

Mr

Miss

Mrs

Ms

Dr

Other

Has the referrer completed any cognitive testing with the individual:

Yes

No

Could you take a short notice appointment?

Yes

No

If English is not your first language, do you require an interpreter?

Yes

No

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