Measuring Form for Suit, Vest, Leotard and Pants

SDO
Sensory Dynamic Orthosis
Unit 13a Harrington Mill, Leopold Street, Long Eaton, Nottingham NG10 4QG
t: +44 (0) 115 973 4300 f: +44 (0) 115 973 3902 www.jobskin.co.uk
Measuring Form for Suit, Vest, Leotard and Pants
Patient details
Purchasers details
Surname:
Address :
First name:
Date of birth: _ _ / _ _ / _ _ _ _
Post code:
Age:
Consultant:
Diagnosis: (Must be completed)
Name:
Measured by:
OT
PT
Orthotist
Jobskin
Hospital order number:
Please indicate: Male
Contact phone number:
Female
Date: _ _ / _ _ / 2 0 _ _
Other Information
Hospital/Clinic:
Wears AFO’s:
Yes
No
Vest / Leotard (delete as appropriate)
No sleeves
PCP01
Gastrostomy site:
Yes
No
Hole required:
Yes
No
If required, please mark position at first fitting only
Vest / Leotard (delete as appropriate)
Short sleeves / Long sleeves (delete as appropriate)
Velcro tabs to attach to pants Yes / No (delete as appropriate)
PCP02
Zips for Vest, Leotard and Suits
Suit
Short leg
No sleeves
Suit
Long leg
No sleeves
PCP03
PCP04
Sleeves:
Suit
Short sleeves / Long sleeves (delete as appropriate)
Short legs / Long Legs (delete as appropriate)
PCP05
Poppers for suits and pants (short leg only):
Pants
Zipper fly / No fly (delete as appropriate)
Short leg / Long leg (delete as appropriate)
Open crotch / Closed crotch (delete as appropriate)
PCP15
Type of SDO required
Trunk stabilising belt
Measuring session fee
Delivery address if different from purchasers:
Delivery address if different from purchasers:
Quantity
Front:
Back:
Crotch:
Closed
Open
Closed
Open
(short leg only)
Upside down
No zip
Upside down
No zip
Inside leg: (short leg only)
(short leg only)
Outside leg:
Full length Back Ulnar side Mid forearm
Leg: Back Front Inside Outside
Inside leg
Fabric colour
White
Beige
Pastel Pink
Navy Blue
Black
Reinforcement
White
Purple
PCP19
Beige
Pastel Pink
Pastel Blue
Black
Royal Blue Red
Camouflage
Bronze
Thread colour
PCP20
Beige
White
Bright Pink
Red
Pastel Pink
Pastel Blue
Purple
Denim Blue
Mint Green
Green
Black
Orange
Royal Blue Bronze
Motif number:
Position:
First SDO:
Yes
No
Tick here if extra reinforcements are required and complete page 3
Post code:
Tick here if special instructions and complete page 3
1
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Circumference
Patient Name:
Lengths
Date of assessment:
E
E
R2
L2
R3
L3
L4
R4
B
R5
PLEASE NOTE:
Measurement 22
is now taken from
the waist
R&L22
L6
Elbow or end of short sleeve
L6
L7
Elbow R6
F
C
R7
L7
R10
R8
Waist
L5
J
D
R9
R11
Measurement
to be taken
A
L9
L11
R13
L13
R13A
L13A
R14
R15
L8
L10
L14 Knee or end of short leg
R20 L20
L15
L16
R16
Knee or end of
garment if
above the knee
R17
R18
L L17
R21 L21
R19
L18
L19
L19
Instep
Instep
Important: For PCP03, PCP04 and PCP05
Measurement R&L 22 must be taken to process your order
For Bra cups and Leotard please complete extra measurements on page 3
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Patient Name:
Date of assessment:
Additional information for measuring for a bra vest:
A
Additional Information required
Please complete extra
measurements for Leotard
or Pants style garments
Normal bra size:
Additional measurements for
Leotard
C
B
A
Overbust Circumference
Waist to waist through
Legs
B
Underbust Circumference
Base of neck to acromion
process (sleeve-less style only)
C
Length from Waist to Underbust
Waist to the end of Leotard at side of body
Additional measurements
for shorts style
Information for bodysuits:
– Please check you have recorded measurement R22 and L22
– This measurement is essential for all bodysuits
Top of shorts to knee
(OR)
End of garment
Please enter Reinforcements Codes required for garment design:
Note: All suits come with the standard panels code: SP - Please tick if not required:
Additional reinforcements codes (see page 4):
Additional information/instructions:
3
© Jobskin 05/2012v7. QR 35/10
CPL
CPR
© Jobskin 05/2012v7. QR 35/10