Amtryke Therapist Assessment

Amtryke Therapist Assessment
This form must be signed off by a licensed PT, OT, or RT
Rider’s Name
Birth Month/Year
Weight (lbs)
Height (inches)
Diagnosis
*This information is private and only utilized to appropriately fit the rider*
Rider Information:
Safety Overview (some riders may benefit from additional safety tools such as rear steering to optimize safety)
Please select any of the below mentioned conditions that your rider may present with
Visual Impairment

YesNo
Behavioral or Cognitive Concerns

YesNo
Uncontrolled Seizures

YesNo
Significant endurance issues

YesNo
Transfer Ability

IndependentMinAModAMaxADependent
Measurements

(these measurements are crucial for an appropriate fit)

A - Acromion process
B - Lateral epicondyle of elbow
C - MCP Joints/Knuckles
D - Greater trochanter
E - Lateral joint line
F - Bottom of foot

Helmet Sizing

	Measurement (head circumference)
Toddler (XS) \| 17.7"-19.3"
Child (S) \| 20.5"-21.7"
Youth (L) \| 21.3"-22.9"
Adult (XL) \| 22.9"-24"

Arms (inches)

	A to B	B to C	Total Length
Left
Right

	A to D
Trunk

Legs (inches)

	D to E	E to F	Total Length
Left
Right

Hip Status

Shoulder

Contractures (severity)

Orthotics used
Equipment
Please list any comments about measurements
Evaluating Therapist Information:
Therapist Name
Are you the treating therapist?

YesNo
Credentials
Completed AEFT Course?

YesNo:
Phone
Therapist comments concerning the rider and family goals
Email
example@example.com
Facility Name
Address

Address

Street Address Line 2

CityState/Zip

Postal / Zip Code
Are you associated with an AMBUCS Chapter?

YesNo
If yes, please indicate
Local AMBUCS Chapter
By signing below, you are signifying that in your professional opinion this rider would benefit from an Amtryke. If this form is being completed by a PTA, COTA, or unlicensed RT or RTA, cosignatory is required due to evaluation component of this form.
Therapist Name (printed)*
Professional Designation
Therapist Signature*

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Date*

MonthDayYear
Date
Cosignatory if necessary

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Date

MonthDayYear
Date
Submitter Information
Submitted By*

First NameLast Name
Submitter Email*
example@example.com
Submitter Phone *
Please enter a valid phone number.
Should be Empty:

	Measurement (head circumference)
Toddler (XS) \| 17.7"-19.3"
Child (S) \| 20.5"-21.7"
Youth (L) \| 21.3"-22.9"
Adult (XL) \| 22.9"-24"

Orthopedic Overview