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Gait Trainers/Walkers Form

Gait trainers and walkers play an important role in building confidence and independence in a child or adult who has difficulty walking on their own. Taking specific measurements and support needs into consideration when choosing one can ensure stable, effective use that significantly benefits the user.

This form is designed to guide you through the process of finding the measurements needed to ensure comfort, safety and function, as well as ask important questions related to the type of product you’re interested in. Once submitted, our customer service representatives will look over your information and send a list of suggested products and accessories that fit your needs.

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 Gait Trainer:
Gait Trainer Style:
Can he/she stand on their own?
YesNo
Is a seat or sling seat required? If yes, which style?
Does he/she require arm prompt support?
YesNo
Does he/she require trunk support?
YesNo
Does he/she require thigh support?
YesNo
Does he/she require ankle support?
YesNo
Will a tray be needed?
YesNo
What other type of support will the user require?
     Measurement
I - Overall Height
K - Bent Elbow to Floor
L - Groin (Inside of Leg) to Floor