Power Assist Rider Checklist

• My wheelchair is properly fitted, but pushing is still difficult
• I prefer a manual wheelchair over a power wheelchair

• I have additional health conditions that make pushing hard (e.g., rotator cuff injury, arthritis, COPD)
• I feel pain in my neck, back, shoulders, arms, wrists, or hands when I push my wheelchair
• I experience numbness or tingling in my arms or hands
• I'm experiencing other issues as a result of pushing my chair (like skin abrasions, pressure sores, spasms, sliding out of my chair, etc.)
• I get tired or out of breath when pushing, even over short distances
• My pain or fatigue with pushing my chair has gotten worse over time

Weakness, paralysis, pain, fatigue, or other symptoms make it difficult for me to:

• Self-propel my wheelchair in my home to get from room to room
• Push my chair over surfaces in my home (carpets, thresholds, and/or ramps)
• Get to the bathroom in time because I can't push my chair fast enough

* Insurance Coverage Criteria: Payers that follow Medicare guidelines cover equipment only when it is determined to be medically necessary for use inside the home.

Weakness, paralysis, pain, fatigue, or other symptoms make it difficult for me to:

• Do necessary daily tasks for myself (like dressing, bathing, or cooking) after the work of pushing all day
• Transfer in or out of my chair because of the work of pushing all day
• Perform my daily living tasks independently in my home because self-propelling with both hands means I cannot carry the items I need

• I have trouble pushing on the surfaces I encounter outside my home, like ramps, curb cuts, or uneven ground
• I need help from others to push me on hills or for long distances
• I slow down or have to rest because I get tired
• I can't push far or fast enough to get where I need to go in a timely manner (like to class or to the bathroom)

• I've had to cut back on activities I enjoy because pushing my wheelchair has become difficult or uncomfortable
• I avoid leaving my home or going to activities because pushing my wheelchair is too hard

• I feel unsafe pushing in certain situations (like up/down ramps, in crowds, or for long distances)
• I struggle to push quickly enough to safely cross streets or navigate busy areas
• I often need help pushing my wheelchair even though I would prefer to be more independent