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Scooter Questionnaire

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Mobility Scooter or Powered Wheelchair Assessment Questionnaire

Personal Details

Medical and Health Information

Please answer the following questions in detail, including any information that you feel may be relevant to operating a mobility scooter or powered wheelchair.

For example, difficulty getting in and out of vehicles.

Please provide any additional information below which may be relevant to you using a mobility scooter or powered wheelchair.

Please answer YES or NO to the following questions and give details where appropriate at the end of this section.

Your eyesight

Your mobility

Your vehicle

For example 'Volkswagon'.
For example 'Polo'.
A Hatchback with two passenger doors is considered to be a 'three door'. Only include passenger doors here.

Herts Ability may, on occasion, feel it appropriate to forward a copy of your assessment report to the agency that referred you and/or your Doctor.

Please could you indicate that you are willing for this to happen by signing below.

Clear Signature

Make a Donation

Minimum Price: £5.00