Physical Disability Needs Evaluation
Full Name
Evaluation Date
1. Personal & Background Information
Date of Birth
Type of Physical Disability
Onset (since when?)
Medical Diagnosis / Notes
2. Mobility & Daily Living
Mobility Level
Independent
With Assistive Device
Requires Assistance
Current Assistive Devices Used
Activities of Daily Living (describe challenges/supports needed)
3. Accessibility & Environment
Home Accessibility Issues
Work/School Accessibility Issues
Transportation Needs
4. Support & Services
Current Support Services Receiving
Additional Needs/Recommended Services
5. Additional Comments
Comments/Observations