Roc Wheels Rockit - Measuring Worksheet

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Patient’s Measurements
(See Diagram Below) cm___ inch___
1) Hip Width _______
2) Seat Depth _______
3) Foot Drop left __ right___
4) Top of Shoulders
to Seat _______
1
3
left
2
4
right
3
Office Info. Only:
What type of wheelchair
would you suggest?
____________________
Person filling out form
____________________
Before picture After picture
4135 Valley Commons Dr.
Suite D.
Bozeman, Montana, USA
59718
Info.@ROCWheels.org
www.rocwheels.org
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