1. What is the overall width of your wheelchair?

Less than 22”
22-26"
More than 26"

2. How high is your seat from the floor?

15.5”/17.5” (Super Hemi/Hemi)
19” (Standard)
More than 19” (Tall)

3. What kind of challenges do you currently face?

I have full arm and hand strength
I have limited arm and hand strength
I have no arm and hand strength

4. Current or future residence:

• Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming