Trexo Home Assessment Form

Welcome!

The following assessment will take approximately 1 hour to complete. You may start it and save it to finish it later. Please answer all questions to the best of your ability. To complete the assessment, you'll need: 1. A measuring tape | 2. Access to a phone/device with video recording capabilities | 3. Your child If your child wears AFO's, please have them on for the measurements | 4. Two people to take measurement pictures and videos
How to save your assessment and get back to it at a later time?

Please scroll to the bottom of the page to click on the SAVE button, and you'll be prompted to login or create an account. It's very important to create an account or login with your credentials to retrieve the filled information at a later point.
What is the name on the reservation? (name of person who put the deposit down)*

First NameLast Name
What is your name? (if different from the reservation holder)

First NameLast Name
What is your email ID? (This email ID will be used for all future communications)*
example@example.com
What is your phone number?*

Area CodePhone Number
Do you consent to receive updates via text?*

Yes, use the number provided aboveNo
Please provide an address for the delivery of your Trexo.*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How did you first hear about us?*

I was referred by someone who has a TrexoFriend or family found itMy physical therapist told me about youSaw you in the newsFound you on social mediaSaw an ad on social mediaOther
Were you referred by someone? Please enter their name:
If you trialed the Trexo at a clinic, please enter the name of the clinic below:

	Difference	Inch	Cm
Leg Length Discrepancy

SECTION 2: The following questions are regarding measurements

You will need a measuring tape, additional person to help and will need to upload some photos & videos
Does your child have AFOs, SMOs, Orthotic shoes or something similar? Please attach a photo of your child wearing them.*

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SHOES (IMPORTANT NOTE)

PLEASE NOTE: If your child uses AFOs, he/she will require High Top Billy shoes over the AFOs. If your child doesn't use AFOs, then he/she will require high top shoes with ankle support, a hard heel cup, and a closed toe. Examples are Timberlands, Memo, Geox, Piedros. Please order the shoe ahead of time as this will be a requirement for use with the Trexo.
How much does your child weigh in lbs?*
What is the hip to armpit length in centimetres when measured as shown below?*

What is the hip to armpit length when measured as shown below?

	Length	Inch	Cm
Hip to Armpit Length

Child Weight:*

	Weight	Lbs.	Kgs.
How much does your child weigh?

Please take 4 pictures of your child's legs wearing their shoes and AFO's (if you have them) as shown in the image below.

Your child should be wearing their AFOs and shoes that you plan to use with the Trexo in these photos. Ensure the markings on the measuring tape are clearly visible and the entire measurement can be seen in the photo. The photos should be uploaded through the links below.
HIP to KNEE - LEFT leg*

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HIP to KNEE - RIGHT leg*

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KNEE to FLOOR - LEFT leg*

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KNEE to FLOOR - RIGHT leg*

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What is the groin to floor length in centimetres when measured as shown below?*
What is the shin circumference in centimetres? Measure it at the widest part of the calf.*
What is the thigh circumference in centimetres? Measure it at the middle of the thigh.*
Grab your child's shoes that they wear with their AFO's or will be using for walking with the Trexo. What is the width of the heel at the widest part of the shoe in centimetres when measured as shown below?*

Circumference of the thigh*

	Width	Inch	Cm
What is the circumference of the thigh measured at the point shown in the image

Grab your child's shoes that they wear with their AFO's or will be using for walking with the Trexo. *

	Width	Inch	Cm
What is the width of the heel at the widest part of the shoe when measured as shown below?

For the same shoes, what is the length of the shoe in centimetres?*

SECTION 3: Please upload assessment videos in this section.

If you're having issues uploading your videos here, you may complete the form and email them to us separately. Please note, all videos are required to complete the assessment.
Please upload a video of your child sitting, standing or walking that represents your child’s typical ability (walk or stand in walker / sit or stand with support– as independently as possible).

If they're not able to use a walker or pacer, you may upload a video of them trying to walk with your support. If that is not possible, please show a video of them standing.

The video should be at least 10 seconds from the front and 10 seconds from the side. You may upload more than one video. Aim the camera to have the full body view in sight. The goal is to help us identify how much support they will require in their Trexo.

Your child should be wearing their AFOs and shoes that they plan to use in the Trexo.
Please upload the video of their sitting, standing or walking here.*

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Please upload a video of your child standing without any equipment. If they require support to stand, please hold them with the minimal possible support (i.e. you can hold them at the armpits, hips, ankles). *

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Please upload the videos of the knee range of motion for both legs here. The instruction video is below for your reference. *

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Please upload the videos of the hip range of motion for both legs here. The instruction video is below for your reference. *

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Welcome!

How to save your assessment and get back to it at a later time?

SECTION 1: Tell us a bit about who will be using the Trexo

SECTION 2: The following questions are regarding measurements

SHOES (IMPORTANT NOTE)

Please take 4 pictures of your child's legs wearing their shoes and AFO's (if you have them) as shown in the image below.

SECTION 3: Please upload assessment videos in this section.

SECTION 4: Physical therapy and additional checks

SECTION 4: Rifton Dynamic Pacer

SECTION 5: Usage

Monitoring your child's progress