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Get Djfs 2004-2024

10/2004) Page 2 of 6 B 3. CLINICAL ASSESSMENT (Continued) MODERATE/SEVERE IMPAIRMENT: Complete when ordering a wheelchair with custom seating or adaptive positioning devices for an individual with a moderate or severe impairment 1. Describe custom seating system in Section C of this form. 2. Is the consumer moderately or severely physically impaired? If yes, Describe the impairment(s): Yes No 3. Indicate the body points of control affected. Head, shoulder & trunk Shoulders, trunk & hi.

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