upright handcycle - ?· upright handcycle evaluation form (jan 19/16) effective january 19, 2016...

Download Upright Handcycle - ?· Upright Handcycle Evaluation Form (Jan 19/16) Effective January 19, 2016 ...…

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  • Upright HandcycleAGE: 714 Years INSEAM: 19"26"

    RIDER INFORMATION Male Female

    Riders Name: ____________________________________________________

    Date of Birth: MONTH ____________ /DAY ____________ /YEAR ___________

    Diagnosis: ________________________________________________________

    Weight: _______lbs. _______kgs. Height: _______inches _______cm

    A. Seat Depth: ________________ inches ___________ cm

    B. Inseam: __________________ inches

    _____________________ cm

    C. Back Height: _______________ inches

    __________________ cm

    D. Seat Width: _______________ inches ___________ cm

    THERAPISTS Name: ______________________________________________

    Phone: ___________________________________________________________

    Fax: ____________________________________________________________

    Email: ___________________________________________________________

    A

    C D

    B

    PAGE SUB-TOTAL

    CHAIN GUARD (Foot Drive Only)E. Total Length: 50" WG: 50 F. Rear steering allows bike to be controlled from the rear, this adds 12" to the length of the model.

    G. Width: 29" WG: 33 H. Steering head tube

    unlocks/locks steering

    E G*Maximum Weight on Removable Rear Platform is 25 lbs.

    TOTAL

    REAR STEERING

    NEW

    FH

    PEDAL POWER (Applicable only to single speed hand or foot drive)

    Easy (std)

    Average (n/c)

    Challenging (n/c)

    H F

    H FH F

    COLOR CHOICE

    Please note extra delivery time for N/c & custom colors.

    Foot Platform (for hand power only)

    Molded ABS Footplate System* XS S M L XL (std)

    BOTTOM BRACKET POSITION

    M. Position of bottom bracket in relation to the seat post. M

    W E C A N C U S T O M B U I L D B A S E D O N Y O U R S P E C I F I C N E E D S !

    PROPULSION

    3-Speed Freewheel w/ Coaster Brake (std)Twist Grip Shift

    TEC Drive - 3-Speed Direct Drive (eAsY, AVeRAge, chAllenging)

    (eAsY, AVeRAge, OFF)

    (std) PLEASE NOTE: Standard shift mechanism for TEC and REC drives.

    NEW

    H F

    H FF

    H F

    H F

    U-Bar R.S. R. Pedal

    U-Bar R.S. R. Pedal

    H F

    NEW

    CRANK ARM LENGTHS - RANGE OF MOTION

    I J K L

    H F

    H FH F

    PARKING BRAKE

    FRAME CHOICE: Hand Only (n/c) Hand & Foot ($501.50) EHD U16N (Narrow) $3,382.99EHD U16 WG (Wide Glide) $3,464.50Custom Frame (call for price)Removable Rear Platform* $296.12

    Rear Steering $570.59

    Adjustable Jogging Extension Handle $170.75

    Candy Blue Hot Rod Purple (std)

    Blue Red Yellow Pink

    Other Custom Color

    Please Specify: ____________________

    Sticker Type Male Female

    Direct Drive (n/c)

    Free Wheel

    Manual Free Wheel / Direct Drive Reciprocator System

    REC - 2-Speed Direct Drive w/ Neutral

    Thumb Shift Lever

    (std)Thumb Shift Lever

    Shorter range is suitable for limited knee flexion.

    I. 3" (79mm) x 26T (n/c)

    J. 4" (102mm) x 32T (std)

    k. 5 (127mm) x 32T (n/c)

    L. Crank Shortener (reduces length by 1/2)

    Standard (3") (n/c)

    Custom ________inches ________cm $170.75

    Heavy Duty Steel Chain Guard (std)

    ABS Enclosed Chain Guard (N/A with TEC and REC Drive)

    Parking Brake (std)Second Parking Brake

    Upright Handcycle Evaluation Form (Jan 19/16) Effective January 19, 2016 Page 1

    RehabmartTypewritten text$118.60

    RehabmartTypewritten text$254.96

    RehabmartTypewritten text$85.42

    RehabmartTypewritten text$219.58

    RehabmartTypewritten text$501.50

    RehabmartTypewritten text$501.50

    RehabmartTypewritten text$74.36

    RehabmartTypewritten text$144.71

    RehabmartTypewritten text$159.90

    RehabmartTypewritten text$132.78

  • PAGE SUB-TOTALCreating a CYCLE of mobilityTM

    SEAT BASE

    1415

    8 9 10 11 12 13 16

    BRAKE LEVER POSITION

    P Q

    ON

    WHEELS

    BACK REST (***Seat is cut away for arm movement)

    Chest Strap (High Back only) (std)

    17. Child Low Back - (13" width, 7.5" height) (n/c)18. Child High Back*** - (13" width, 18" height) (std)

    (Includes Custom Back) (2 Required for Set)

    A. chesT WidTh ______ inches ______ cm b. seAT TO ARmpiT ______ inches ______ cm

    17

    AB

    18 19 20 21 22

    TIRES

    PEDALSMeasure Riders Shoe: i) _____ inches _____ cm ii) ______ inches ______ cm OR TRACE OUTLINE OF RIDERS SHOE ON A PIECE OF PAPER & SUBMIT w/ORDER.

    5 76

    3 42

    ii

    i

    Shoe Heel Widest Point

    Shoe length

    1

    HAND PEDALS

    R S T U V

    HEAD REST

    PLEASE NOTE: Required for addition of Adjustable Rain and Sun Shade Canopy

    24. Adjustable Velcro Occiput Support Cushion PLEASE NOTE: Includes Adjustable/Removable Headrest option.

    25. i2i Head & Neck Support System with Support Bracket PLEASE NOTE: Please specify size as per brochure.26. Headpod Support System with Support Bracket PLEASE NOTE: Includes Adjustable/Removable Headrest option.

    Custom - Custom Mount of Head Support Bracket (Template required) (call for price)

    heighT: ________ inches ________ cm WidTh: ________ inches ________ cm

    Adjustable Rain & Sun Shade Canopy PLEASE NOTE: Requires the Adjustable/Removable Headrest

    26252423

    N. 16" Aluminum (std)O. Spoke Covers (set of three)

    P. 16" Smooth Solid Tires (Aluminum Wheel only) (std) Q. 16" Knobby 16 Smooth

    Coaster Brake (std)Front Brake (Please specify 1st lever position) (n/c)

    Second Brake Lever* (splitter)

    Optional Rear Band Brake (EHD U16WG only)*

    LEVER POSITIONING 1st LEVER (std) 2nd LEVER* Left Pedal

    Right Pedal

    Rear Assistance (T-bar)

    Rear Steering Handle

    Effective January 19, 2016 Page 2

    6. Pulley System (FRONT: corrects plantar flexion) Pulley System (REAR: self-leveling pedals) 7. Abductor Leg Brace *requires #5 Molded ABS Footplate S M L

    1. Mountain Style Pedal (std) 2. with Cage ($42.65)3. Neoprene Adjustable Footplate* S M L XL 4. Molded ABS Footplate System* XS S M L XL5. Molded ABS Footplates with Ratcheting Straps Size Options: XS S M L XL

    Please specify Left or Right 0.25 Footplate Spacers Qty: ______/Pedal ($13.66/uniT)

    R. Bar End Grip Pedals (std)S. T-Handle Pedal (required for brake lever on pedal) T. Quad Cuff Grip U. Foam Covered Straight Grip V. Foam Covered Ergo Grip

    8. Child (12.5" width, 12.5" depth) (std)9. Child Narrow

    10. Adult Seat (16.75" width, 14" depth) (WG only)

    11. Adult Narrow (WG only)

    12. Add 2" Raised Pommel to seat selection above

    13. Custom (measurements) (call for price)

    A. ________ inches ________ cm B. ________ inches ________ cm

    14. Hip Belt 1.5" wide (n/c)

    15. Hip Belt, 2" wide (std)16. Neoprene Hip Stabilizer Belt

    19. Adult Low Back - (17" width, 10" height) (WG only) 20. Adult High Back*** - (17" width, 18" height) Recline bAck 21. TilT seAT

    22. Lateral Support Bracket complete w/Track S L ($352.71/EA)

    23. Adjustable/Removable Headrest

    RehabmartTypewritten text$118.60

    RehabmartTypewritten text$107.54

    RehabmartTypewritten text$107.54

    RehabmartTypewritten text$132.78

    RehabmartTypewritten text$42.65

    RehabmartTypewritten text$42.65

    RehabmartTypewritten text$332.13

    RehabmartTypewritten text$373.30

    RehabmartTypewritten text$457.08

    RehabmartRectangle

    RehabmartTypewritten text($486.69/ea)

    RehabmartTypewritten text$118.60

    RehabmartTypewritten text$154.47

    RehabmartTypewritten text$154.47

    RehabmartTypewritten text$311.56

    RehabmartTypewritten text$107.54

    RehabmartTypewritten text$107.54

    RehabmartTypewritten text$107.54

    RehabmartTypewritten text$107.54

    RehabmartTypewritten text$192.45

    RehabmartTypewritten text$65.05

    RehabmartTypewritten text$107.54

    RehabmartTypewritten text$187.03

    RehabmartTypewritten text$197.88

    RehabmartTypewritten text$342.43

    RehabmartTypewritten text$973.30

    RehabmartTypewritten text$674.22

    RehabmartTypewritten text$321.84

  • CHEST HARNESS

    Creating a CYCLE of mobilityTM

    STATIONARY TRAINER

    Total - Page 3

    Total - Page 2

    Total - Page 1

    SUB-TOTAL

    TOTAL

    ABDUCTOR/ADDUCTION

    27 28

    GLOVES

    Hand Tracing RequiredB

    A

    A. Measure width of palm _____ inches _____ cm

    B. Measure width of wrist _____ inches _____ cm

    C. Measure bend of wrist to top of middle finger _____ inches _____ cm

    C

    PRIVACY POLICYFreedom Concepts Inc. collects, uses and discloses personal information of the Customer and/or Rider to properly assemble and manufacture the mobility deviceand may contact the Riders therapist for additional personal information to assistwith this process. The collection, use and disclosure of the personal informationof the Customer and/or the Rider is governed by any consent which may, from timeto time, be provided, and by the Freedom Concepts Inc. P