Yes

No

Question

Do you experience increased anxiety when driving your power mobility device?

Have you often gotten lost in your facility when driving your device?

Do you have identified vision problems, such as macular degeneration, glaucoma, or cataracts that may cause difficulty noticing objects or people in your pathway?

Do you have difficulty using the joystick or other device controls?

Have you experienced difficulty reacting quickly [to stop] when someone walks in front of you, or if an object were in your pathway?

Have you recently hit any walls, door frames, objects, or people when driving your device?

Have you noticed scrapes or dents on the device or other objects or walls in your apartment/home?

Have you had “close calls” when driving?

Do you have trouble navigating turns or parking your device?

Do family members or staff express concern with your capacity to drive your power mobility device?