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

First Name Last 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 Code Phone Number
Please provide an address for the delivery of your Trexo.*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
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 media
Were you referred by someone? Please enter their name:
If you trialed the Trexo at a clinic, please enter the clinic below:
Do you consent to receive updates via text?*

Yes, use the number providedNo
SECTION 1: Tell us a bit about who will be using the Trexo
What is your child's name?*

First Name Last Name
What is your child's date of birth?*

MonthDay Year
Date
What is your child's gender?*

MaleFemale
What condition(s) is your child diagnosed with?*

CP- all 4 limbs affected, muscles stiff, (spastic quadriparesis)CP- lower half of body more affected than upper half, muscles stiff, (spastic diplegia)CP- non-spastic, trunk muscles may be more affected than limbs (ataxic or dyskinetic)Brain Injury - when did it occur? What was the cause (TBI vs anoxic injury)Genetic syndrome- please provide detailOther - please provide detail
Please describe all diagnoses in as much detail as possible.*
Is your child able to complete the following without assistance?*

None, N/ARollCrawlSitStandWalk
How is your child's head control?*

Poor, needs help with head controlOk, can hold up head sometimesPretty good, can hold head up most of the timeGood, can control and hold head up
How is your child's walking ability?*

Cannot walk or initiateCan take a couple of steps with assistanceCan walk short distance with a walker or pacerCan get around with a walker or pacer comfortablyCan walk independently or with crutches
Describe your child's muscle tone around the legs.*

Generally low toneNormalGenerally high tone
Has your child ever fractured or broken a bone?*

YesNo
If yes, provide more detail about the fracture or broken bone. When did it occur? Are they approved for weight bearing?
Has your child ever been diagnosed with any other medical conditions which make it dangerous to exercise or weight bear? Please describe in as much detail as possible.*
Does your child use a standing frame?*

YesNo
What is the name of the stander?*
How frequently and how long do you use the stander? (Eg daily 1hr)*
What configuration do you use the stander in?*

UprightSupineProne
Does your child have knee contractures in either of the legs? (A contracture is a fixed tightening of muscle, tendons, ligaments, or skin, which prevents normal movement of the associated body part).*

Yes, both legsYes, one sideNo
How severe are the knee contractures? Please specify degree if known.
Does your child have hip subluxation in either of the legs?*

Yes, both legsYes, one sideNoI don't know
How severe is the hip subluxation? Please specify degree of migration if known.
Does your child have a leg length discrepancy? If so, how much?*

No
How is the leg length discrepancy being managed? Eg, riser in shoes, AFOs
Has your child had or is scheduled to have spinal fusion surgery?*

YesNo
Please provide additional details on the spinal fusion surgery.
Does you child have a seizure disorder?*

YesNo
Is the seizure controlled*

YesNo
Does your child take any medication for the seizure*

YesNo
Please indicate the medicine and the frequency of the medication for seizures.*
What type of seizures does you child have? Describe the tone and how you are able to know that your child is having a seizure.*
Do you use any other methods or devices to control the seizures (eg. implanted nerve stimulator VNS)*
Is there any other medical reason that would make your child not suitable for the Trexo?*

YesNo
Please explain the medical reason that would make your child not suitable for the Trexo*
What are your hopes or goals to achieve with getting the Trexo Home device for your child?*
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?*
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 - right leg*

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Hip to knee - left leg*

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Knee to floor - right leg*

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Knee to floor - left 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?*
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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SECTION 4: Physical therapy and additional checks
Is your child receiving physical therapy or have they previously?*

Yes, currently receiving therapyYes, received therapy before but stoppedNo, my child does not have a therapist
Please describe your child's physical therapy regimen.
What is the name of your child's physical therapist (PT)?

First Name Last Name
Please provide your PT's contact information and address.
Does Trexo have your permission to contact your PT if we have any additional questions regarding your child using the Trexo safely?

YesNo
SECTION 5: Rifton Dynamic Pacer

You need a Rifton dynamic pacer to use with the Trexo Home device. The pacer is not included with the Trexo and can be purchased separately through Trexo at discounted prices or through your insurance.
Are you purchasing a Rifton Dynamic Pacer to own through us?*

Yes, I'm going to buy it at discounted prices from Trexo RoboticsNo, I have one alreadyNo, I will buy it through insuranceNo, I will buy it through other means
IMPORTANT:

Please make sure that you do not order the Rifton Pacer until the exact set of accessories and sizes is provided to you by us. The fitting of the Rifton is different with the Trexo compared to how a DME company or a PT would setup.
What colour Rifton would you like?

GreenBluePinkRedGrey
Do you currently have the Rifton in your possession?

Yes, we already have a Rifton Dynamic PacerWe have ordered the pacerWe plan to order the pacer
What size Rifton Pacer do you have?

SmallMediumLargeX-Large
Please attach a photo of your Rifton Pacer. This will help us ensure you have the correct size pacer with the necessary accessories to use the Trexo.

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SECTION 6: Usage
How many times a week do you plan to use the Trexo?*
We recommend daily
Do you primarily plan to use the Trexo indoor or outdoors?*

IndoorsOutdoors
Please note: The Trexo requires constant supervision and monitoring while it is under use. I cannot leave my child unattended in the device.*

I understandNo, I am unable to proceed
Please describe the area where you intend to use the Trexo, including environment, space.
Eg, I plan to use the Trexo in our basement, which has a 15ftx30ft space for walking.
Please describe the terrain where you intend to walk
Eg, carpet, gravel, pavement
Trexo sells a treadmill ($1000) if there is limited space indoor or bad weather outdoors? Would you be interested to learn more?

Yes, we will need oneNot interestedUnsure, open to learn more
Is your child attending school in-person?*

Yes, currently going dailyNo, not going and don't plan to go within the coming 12 monthsNo, but plan to start going within the coming 12 months
Would you like to consider using the Trexo at school? It allows your child to engage with peers and participate in activities, while getting daily exercise and training in the Trexo.*

Yes, I'm interested, tell me moreNo, I'm not interested
What questions do you have about the Trexo that you would like to get answered before starting?
What other things would you like to tell us about your child that are not covered in the assessment?
Monitoring your child's progress
Trexo is partnering with a research institute in Calgary to collect information about the benefits of the Trexo on children with disabilities. The study outcomes can be used to quantitatively show the collective benefits of the Trexo for children. This data is very helpful for us to build a case for getting the Trexo covered by insurance in the future. You are paving the way for bringing this technology into the hands of many others. Do you consent to Trexo sharing your contact information with the researcher so they can ask you additional questions?*

I consentI do not consent
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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 5: Rifton Dynamic Pacer

SECTION 6: Usage

Monitoring your child's progress