PATIENT REFERENCE NO.: FIRST NAME: SURNAME: Date of Birth: Male Female Please indicate: New Patient Existing Patient Diagnosis (must be completed):

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1 Please indicate specific garment by selecting the relevant tick box. Type of SDO Required Product No. Quantity No Sleeves Short Leg PCP03 Open Crotch Closed Crotch No Sleeves Long Leg Open Crotch Short Sleeves Short Legs Open Crotch Measuring session fee Closed Crotch Long Sleeves Long Legs Closed Crotch Any other information, if required attach separately Delivery Address Post code: PCP04 PCP05 PCP20 Sensory Dynamic Orthosis Unit 13a Harrington Mill, Leopold Street, Long Eaton, Nottingham, NG10 4QG t: +44 (0) f: +44 (0) e: w: Patient Details (Please complete Patient Ref. No. OR Name) Date of Birth: Male Female Please indicate: New Patient Existing Patient Diagnosis (must be completed): Date: Hospital/Clinic: Personalisation Choices Fabric Colour: Reinforcement Panel Colour: Thread Colour: (Please indicate using code or name) Motif: Binding: Printed Zipper: Wears AFO s Yes No Gastrostomy Yes No site: If required, please mark position at first fitting only. Hole required: Yes No If required, please mark position at first fitting only. Front: Closed Open Upside down No Zip Back: Closed Open Upside down No Zip Crotch: Short Leg only Zips for Suit: Inside Leg: Short Leg only Outside Leg: Short Leg only Sleeves: Full length Back Ulnar side Mid Forearm Leg: Back Front Inside Outside First SDO: Yes No Purchasers Details Address: Consultant: Name: Post Code: Measured by: OT PT Orthotist Jobskin Hospital Order No.: Contact Phone No.: Fabric Colour Pastel Pink Navy Blue Reinforcement Panel Colour Pastel Pink Red Bronze Pastel Blue Purple Pink Royal Blue Floral Paisley Camouflage Marvel Bull Dog Unicorn Thread Colour Pastel Pink Red Bronze Pastel Blue Purple Pink Royal Blue Yellow Orange Bright Pink Navy Denim Mint Green Green Blue When completed, please fax or back to Jobskin - Fax: orders@jobskin.co.uk Page 1 of 5 Jobskin Ltd JSIFU097-V11 04/2019 Review 04/2021

2 Reinforcement Panels for Suits (Please select panel and tick box) Standard Panels Lumbar Panels Lateral Trunk Panels Lateral Trunk Panels Chest Panels Cross Panels Abdominal Panels Back Panels To assist hip external rotation To assist postural control To correct left lateral flexion To correct right lateral flexion To assist protraction of the To assist retraction of the To resist lordosis To resist kyphosis and back extension scapulae scapulae and back extension SP (Std Panels included with Suits) LP TPL TPR CP1 CP2 AP BP Hip Panels Oblique Panels Medial Upper Leg Panels Pelvic Panels Pelvic Panels Leg Panels Leg Panels Leg Panels To assist hip control and To assist activation of oblique To assist adduction and To resist posterior tilt To resist anterior tilt and To assist knee extension To assist knee flexion To assist hip extension external rotation muscles internal rotation encourage hip extension HP OB ULM APP PPP KE KF HE Scoliosis Panels Scoliosis Panels C-Shape Scoliosis Panels C-Shape Scoliosis Panels External Rotation Panels Internal Rotation Panels To assist correction of right thoracic and left lumbar curves To assist correction of left thoracic and right lumbar curves To resist falling to the left To resist falling to the right To assist external rotation at the hips To assist internal rotation at the hips SPL SPR CPL CPR ERP IRP Page 2 of 5 Jobskin Ltd JSIFU097-V11 04/2019 Review 04/2021

3 REFER TO MEASUREMENT GUIDE ON PAGE 4 TO RECORD YOUR MEASUREMENTS OR USE PAGE 5 AND RECORD YOUR MEASUREMENTS IN THE DIAGRAM BOXES. IMPORTANT: MEASUREMENTS R22 AND L22 MUST BE TAKEN. WITHOUT THIS, WE ARE UNABLE TO PROCESS YOUR ORDER. FOR DESCRIPTION OF MEASUREMENTS SEE PAGE 4. Additional information for measuring for a Bra Vest Normal Bra size: Measurements for Bra cm A B C Overbust circumference. Underbust circumference. Length from waist to underbust. Circumference Lengths Page 3 of 5 Jobskin Ltd JSIFU097-V11 04/2019 Review 04/2021

4 Measurement for Suits - Circumferences Left (cm) Right (cm) A B E J 2 3 Level with umbilicus 1cm less than at rest circumference. Level with chest in line with the axillary crease. Base of the neck. Level with Superior Iliac Spine (ASIS). Shoulder joint from base of the neck (at point where neck meets shoulder below ear lobe), under the axilla and back to the same point. (Scapula set against the chest wall and the arm by the side of the body). One should be able to slide 1 finger under the tape measure at the front of the axilla. Shoulder joint acromion process under the axilla and back to the same point. (Scapula set against the chest wall and the arm by the side of the body). One should be able to slide 1 finger under the tape measure at the front of the axilla. 4 Upper arm level with axilla. Arm should be by the side. 5 Mid upper arm level with muscle bulk of biceps, reduce at rest measurement by 5mm. 6 Elbow joint with arm extended or end of sleeve. 7 8 Forearm level where muscle bulk is greatest, reduce at rest measurement by 5mm. Forearm at musculotendinous junction (approximately 1/3 of forearm up from the wrist). 9 Wrist level with wrist crease or at point where sleeve ends. 13 Leg level with the groin and gluteal fold. 13A Mid-thigh level with muscle bulk 5mm less than at rest circumference. 14 Above knee at suprapatellar margin or where shorts end. 15 Level with knee joint (in line with mid patella). NOTE: USE THIS PAGE TO RECORD YOUR MEASUREMENTS OR PAGE 5 AND RECORD THE MEASUREMENTS IN THE DIAGRAM BOXES. Measurement for Suits - Lengths Left (cm) Right (cm) C D F Point level with axillary crease measure down side to a point level with umbilicus. Point level with umbilicus to Superior Iliac Spine (ASIS) on anterior surface. 2cm below sternal notch to umbilicus on the anterior surface of the chest with the ribs held in best position of alignment. This measurement dictates the scoop of the neck. 10 Axilla to cubital crease on the medial border or to end of short sleeve. 11 Point level with the cubital crease to wrist crease or end of long sleeve along ulnar border of forearm. 20 Inside leg groin to knee or end of SDO Knee joint in line with mid-patella to upper margin of medial malleolus - measured on medial border. Point level with umbilicus on anterior surface to knee or end of shorts or long leg pants. Note: Measurements R22 and L22 must be taken. Without this, we are unable to process your order. 16 Below knee at upper margin of tibial tuberosity. 17 Level with bulk of calf 5mm less than at rest circumference. 18 Level with mid-lower leg, at point of musculotendinous junction. Additional information for Sleeveless Suits Left (cm) Right (cm) 1 Acromion to base of neck or width required for Sleeveless Suit. 19 Level with upper margin of medial malleolus. Instep Around instep or waist of the foot (only if stirrup required). Page 4 of 5 Jobskin Ltd JSIFU097-V11 04/2019 Review 04/2021

5 Please make sure when measuring for a SDO garment that the patient is measured lying down, supine and in the best position of alignment. IMPORTANT: MEASUREMENTS R22 AND L22 MUST BE TAKEN. WITHOUT THIS, WE ARE UNABLE TO PROCESS YOUR ORDER. FOR DESCRIPTION OF MEASUREMENTS SEE PAGE 4. Circumference Lengths Page 5 of 5 Jobskin Ltd JSIFU097-V11 04/2019 Review 04/2021