SHONAQUIP: Measurements and personal information

NB: Measure the child in normal everyday clothes e.g. T-shirt and
tracksuit pants. Please note that measurements need to be accurate
to ensure optimal support. Allowance for growth and thickness of
clothes will be taken into consideration during manufacture.

BACK HEIGHT

Support the body in a symmetrical position. (NB. facilitate full lower back extension)
  1. Bottom of butt to nipple (arm hanging down)
/
mm
  1. Bottom of butt to level with top of head

mm

FULL BODY

Measure the following working bottom to top:
  1. Heel to knee
/ mm /
  1. Knee to the pelvis
/ mm
  1. Pelvis to the shoulder
/ mm
  1. Pelvis to top of the head
/ mm

HEAD CONTROL

Is head support necessary? / Yes / No
Please indicate degree of control on a scale of 1 to 10
1 = no control - 10 = good
Is there too much tone? (ie. extension of the neck)
Yes / No
Is the lack of head control due to hypotonia (low tone)?
Yes / No
Is there an asymmetrical tonic neck reflex? / Left / Right

HIP WIDTH

/
Measure straight across the back of the hips at the widest point (not around the corners)
mm

SHOULDER WIDTH

/
Measure straight across the back of the shoulder at the widest part
mm

TRUNK CONTROL

Can the child sit unaided? / Yes / No
If the child is sitting on your lap can she maintain balance with some support? /
Yes / No
To which side will the child lean/fall if not supported?
Left / Right
Is there lordosis? (hollow lower back) / Yes / No
Mobile / Fixed
Is there kyfosis? (rounded back)
Yes / No
Is there scoliosis? / Yes / No
Mobile / Fixed
Enclose detailed photographs.
Is there rotation of the upper trunk? / Yes / No
Mobile / Fixed
Left / Right

FOOTREST HEIGHT

/
Measure from bottom of the heel to the back of the knee
mm
Are contractures present? (tight joints)
Yes / No
Enclose detailed photographs of affected joints. Show range of joints.
Right hip / Right knee / Right foot
Left hip / Left knee / Left foot

FOOT SUPPORT

Do the feet:
  1. Cross over midline
/ Yes / No
  1. Kick out forward
/ Yes / No
  1. Kick out sideways
/ Yes / No
  1. Pull up into flexion
/ Yes / No
Enclose detailed diagram and photographs.

ABDUCTION OF THE LEGS

Abduction of the legs (moving the legs apart) to widen the seating support base often improves balance and symmetry.
Is there a tightness when abducting the legs whilst in a sitting position?
Yes / No
Does the degree of abduction reduce tone?
Yes / No
How far can one comfortably abduct the legs?
mm
Is one leg tighter than the other?
Right / Left

ADDUCTION OF THE LEGS

Do the legs flop apart? / Yes / No

SEAT DEPTH

Place child on firm surface - maintain lower back extension.
Measure from behind knee to back of butt /
mm
Is the measurement the same on both legs while in this position?
Yes / No
If not:
Left leg butt to back of knee
mm
Right leg butt to back of knee / mm
Is one leg longer than the other as a result of hip dislocation?
Yes / No
Is it possible to get extension in the lower back?
Yes / No
Is the pelvis rotated? / Yes / No
Mobile / Fixed
Is there an obliquity of the pelvis? /
Yes / No
Mobile / Fixed / Right / Left
Measure the distance between the seat and the buttocks
mm

SHONAQUIP CUSTOMER INFORMATION

Name in full
Date of birth
ID number
Spouse’s name in full
Child’s Name
Date of Birth
Residential / Delivery address
Postal address
Work Tel / Code
Home Tel / Code
Cell
Fax / Code
Person responsible for account
To which address must account be sent
Marital status
Contact person/next of kin
Contact number / Code
Medical Aid scheme
Medical Aid number
M/Aid Tel / Code
M/Aid fax / Code
Therapist’s name
Tel / Code
Settlement of the account is the responsibility of the purchaser.
Print Name
Signed
Date

Fax the completed form to Shonaquip on 021 797 8239 or
post it to 3 Tiverton Rd, Plumstead 7800, Cape Town