A) The patient has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that: Prevents the patient from accomplishing an MRADL entirely, or Places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or Prevents the patient from completing an MRADL within a reasonable time frame.	YesNo
B) The patient’s mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker.	YesNo
C) The patient does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function. An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options,and other appropriate non-powered accessories.	YesNo