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Car Seats/Strollers/Swing Seats Form

Getting your client or loved one out and active is an important part of their daily routine. By taking the time to examine the measurements and needs of the user closely, you can ensure that you’re choosing the most suitable adaptive car seat, stroller or swing seat for them.

First Name *
Last Name*
Organization
Title
Address *
City *
State/Province *
Country *
Zip/Postal Code *
Phone *
Fax
Email *
Yes, I would like to receive eNews from eSpecial Needs
What is his/her overall height?
What is their overall weight?
Age?
Model of Product?
Which product were you interested in?

For Strollers:

Can he/she sit up on his/her own?
YesNo
Model of Stroller?
Stroller Style:
Will stroller/pushchair need to meet crash tests for bus transport?
YesNo
Does the seat need to tilt and/or recline?
YesNo
Does he/she need armrests on the chair?
YesNo
Does he/she thrust his pelvis to move out of the chair?
YesNo
Do their legs scissor in or out?
YesNo
Are foot positioners needed to adjust foot position and angle?
YesNo
Do feet need to be strapped down to footplate?
YesNo
Do his/her legs need to elevate?
YesNo
Does he/she require support for his chest and trunk to hold him up and in place?
YesNo
Does he/she require lateral support to prevent from leaning?
YesNo
Does he/she require support for his/her head?
YesNo
Is a sunshade needed?
YesNo
Will a tray be needed?
YesNo
Will basket or holders for oxygen tanks be required?
YesNo

For Car Seats:

Do their legs scissor in or out?
YesNo
Is a guard required to prevent the child from releasing the harness?
YesNo
Will a tray be needed?
YesNo

For Swing Seats:

Can he/she swing on their own or do they require assistance?
YesNo
Does he/she require back and/or head support?
YesNo
Can he/she sit up on their own?
YesNo
Does he/she need to be reclined for comfort or support?
YesNo
Is additional head or leg support required?
YesNo
What other type of support will user require?
     Measurement
A - Shoulder Width
B - Hip Width
C - Seat To Top Of Head
D - Bottom Of Seat To Shoulder
G - End Of Seat To Inside of Knee
H - Back Of Knee To Back Of Heel