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  Orbit Medical >> Electric Wheelchairs >> Mobility Quiz

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First Name:
Last Name:
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Comments:
I want to receive information
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  1. What is your current level of physical mobility?
    • Bed or chair bound
    • It is painful to move around
    • Mobile with frequent falls
    • Other
  2. How would you describe your ability to complete your daily activities?
    • Easy
    • With Some Difficulty
    • Difficult
  3. Do you have Medicare or another private insurance provider?
    • Yes
    • No
  4. Have you tried to qualify through Medicare or your insurance to receive a wheelchair, but have been denied?
    • Yes
    • No
  5. Do you have difficulty using a manual wheelchair, a cane, or a walker?
    • Yes
    • Sometimes
    • Never
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* The cost of durable medical equipment is dependent on individual insurance benefits and medical qualifications.
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