Massachusetts Commission for the Blind O&M Medical Clearance Form

Your patient is being referred for Community Orientation & Mobility (O&M) Training, which may involve activities such as walking independently for up to 60 minutes or more, crossing streets, and using public transportation. To ensure the individual's safety and ability to participate, we ask that you complete this form to identify any physical limitations that may affect their participation in the training.

Please note that are team is not comprised of physical therapists and we do not offer physical therapy services.

If you have any questions regarding the O&M training, please contact Michelle Pfeiffer at michelle.pfeiffer@mass.gov

Patient's Name(Required)
Patient's City/Town(Required)
Patient's Date of Birth(Required)

Does the individual have any medical conditions, other than blindness, that could limit or prevent participation in any of the following activities:

Ascending and descending stairs with a handrailing(Required)
Walking for extended periods of time (15 to 20 minutes)(Required)
Walking independently without the use of a support cane or walker(Required)
Walking more than 20 minute in excessive heat or cold weather(Required)
Using public transportation(Required)
Is the individual a candidate for a support cane?(Required)
Does the individual require a referral for physical therapy?(Required)

Please initiate a referral for physical therapy.

Does the individual have any neurological complications or memory issues?(Required)
Does the individual experience frequent diabetic reactions?(Required)
Today's Date(Required)
Doctor's Name(Required)
Doctor's Address(Required)
Consent(Required)