Wheelchair Monthly Checklist

• Site conducted

  Select

• Conducted by

  Date

Wheel Chair Check

• Wheelchair #

• Ensure the seat height is comfortable

  Yes

  No

  N/A

• Check the Armrests and footrests

  Good

  Fair

  Poor

  N/A

• Make sure limb restraints are in place

  Yes

  No

  N/A

• Check Log book is up to date:

  Yes

  No

  N/A

• Check the cushion and back support

  Yes

  No

  N/A

• Check the frame type

  Good

  Fair

  Poor

  N/A

• Check wheelchair brakes

  Good

  Fair

  Poor

  N/A

Completion

• Conducted on

  Date

• Name and Signature

  Sign