Mobility Aid Quiz

1
What type of mobility aid are you looking for?* This field is required.
Power Wheelchair
Manual Wheelchair
Scooter
None
2
Answer: Do you currently have a power wheelchair, manual wheelchair or scooter?
3
Calculation: Do you currently have a power wheelchair, manual wheelchair or scooter?
4
How soon do you need your wheelchair or mobility product?
Today
Within 1 month
Within 3 months
More than 3 months
5
Answer: How soon do you need your wheelchair or mobility product?
6
Calculation: How soon do you need your wheelchair or mobility product?
7
Are you over age 65?* This field is required.
Yes
No
8
Answer: Are you over age 65?
9
Calculation: Are you over age 65?
10
What is your height?* This field is required.
Less than 5 feet
Between 5 - 6 feet
Over 6 feet
11
Do you weigh over 285lbs?* This field is required.
Yes
No
12
Is any part of your body paralyzed?* This field is required.
Yes
No
13
Answer: Is any part of your body paralyzed?
14
Calculation: Is any part of your body paralyzed?
15
Do you have an existing pressure sore or a history of pressure sores on your back or buttocks?* This field is required.
Yes
No
16
Answer: Do you have an existing pressure sore or a history of pressure sores on your back or buttocks?
17
Calculation: Do you have an existing pressure sore or a history of pressure sores on your back or buttocks?
18
Have you had a stroke?* This field is required.
Yes
No
19
Answer: Have you had a stroke?
20
Calculation: Have you had a stroke?
21
Do you have insurance?* This field is required.
Yes
No
22
Answer: Do you have insurance?
23
Calculation: Do you have insurance?
24
If Yes, pick one:* This field is required.
Medicare
Medi-Cal
HMO (Kaiser, Molina, CHG, IEHP, Riverside, etc.)
Blue Cross, Blue Shield or United Health Care
TriCare
Workman’s Comp
Cash
PPO
Other
25
Answer: If Yes (insurance)?
26
Calculation: If Yes (insurance)?
27
Do you have secondary insurance?* This field is required.
Yes
No
28
Answer: Do you have secondary insurance?
29
Calculation: Do you have secondary insurance?
30
Has your condition or disease been diagnosed by your doctor?* This field is required.
Yes
No
31
Answer: Has your condition or disease been diagnosed by your doctor?
32
Calculation: Has your condition or disease been diagnosed by your doctor?
33
If Yes, pick all that apply:* This field is required.
Amputation
Traumatic Brain Injury
Lymphedema
Spinal Cord Injury
Parapalegic / Quadrapalegic
Cerebral Palsy (CP) / Multiple Sclerosis (MS)
Amyotrophic Lateral Sclerosis (ALS)
Muscle Disorder
Other
34
Answer: If Yes (Conditions)
35
Calculation: If Yes (Conditions)
36
Name* This field is required.
First Name
Last Name
37
Email* This field is required.
example@example.com
38
Phone Number* This field is required.
Area Code
Phone Number
39
What city are you in?
type city here
40
Consent for Senior Mobility Aids to contact you regarding this submission* This field is required.Privacy policy here: https://seniormobilityaids.net/privacy-policy/
I consent
41
Calculation: total score
42
utm_source
43
utm_campaign
44
utm_medium
45
utm_url
Should be Empty: