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Scooter Questionnaire

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Mobility Scooter or Powered Wheelchair Assessment Questionnaire

Personal Details

All information provided will be treated as confidential.

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.

Please answer YES or NO to the following questions and give details where appropriate.

Eyesight

Mobility

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?

By signing this form, you also declare that the information provided is true and correct.

Clear Signature

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