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Patient Medical Questionnaire
In order to safely review your order, we require information about the prescribed patient.
If you are ordering for yourself, please provide your information.
If you are ordering for a family member or pet, please answer these questions on their behalf.
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Height of patient (or choose "animal" if pet)*
Animal
3′0″ (91.44cm)
3′1″ (93.98cm)
3′2″ (96.52cm)
3′3″ (99.06cm)
3′4″ (101.6cm)
3′5″ (104.14cm)
3′6″ (106.68cm)
3′7″ (109.22cm)
3′8″ (111.76cm)
3′9″ (114.3cm)
3′10″ (116.84cm)
3′11″ (119.38cm)
4′0″ (121.92cm)
4′1″ (124.46cm)
4′2″ (127cm)
4′3″ (129.54cm)
4′4″ (132.08cm)
4′5″ (134.62cm)
4′6″ (137.16cm)
4′7″ (139.7cm)
4′8″ (142.24cm)
4′9″ (144.78cm)
4′10″ (147.32cm)
4′11″ (149.86cm)
5′0″ (152.4cm)
5′1″ (154.94cm)
5′2″ (157.48cm)
5′3″ (160.02cm)
5′4″ (162.56cm)
5′5″ (165.1cm)
5′6″ (167.64cm)
5′7″ (170.18cm)
5′8″ (172.72cm)
5′9″ (175.26cm)
5′10″ (177.8cm)
5′11″ (180.34cm)
6′0″ (182.88cm)
6′1″ (185.42cm)
6′2″ (187.96cm)
6′3″ (190.5cm)
6′4″ (193.04cm)
6′5″ (195.58cm)
6′6″ (198.12cm)
6′7″ (200.66cm)
6′8″ (203.2cm)
6′9″ (205.74cm)
6′10″ (208.28cm)
6′11″ (210.82cm)
7′0″ (213.36cm)
7′1″ (215.9cm)
7′2″ (218.44cm)
7′3″ (220.98cm)
7′4″ (223.52cm)
7′5″ (226.06cm)
7′6″ (228.6cm)
7′7″ (231.14cm)
7′8″ (233.68cm)
7′9″ (236.22cm)
7′10″ (238.76cm)
7′11″ (241.3cm)
8′0″ (243.84cm)
Please indicate the patient’s weight
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Weight of patient (or choose "animal" if pet)
Animal
30 kg / 66 lbs
31 kg / 68 lbs
32 kg / 70 lbs
33 kg / 72 lbs
34 kg / 74 lbs
35 kg / 77 lbs
36 kg / 79 lbs
37 kg / 81 lbs
38 kg / 83 lbs
39 kg / 85 lbs
40 kg / 88 lbs
41 kg / 90 lbs
42 kg / 92 lbs
43 kg / 94 lbs
44 kg / 97 lbs
45 kg / 99 lbs
46 kg / 101 lbs
47 kg / 103 lbs
48 kg / 105 lbs
49 kg / 108 lbs
50 kg / 110 lbs
51 kg / 112 lbs
52 kg / 114 lbs
53 kg / 116 lbs
54 kg / 119 lbs
55 kg / 121 lbs
56 kg / 123 lbs
57 kg / 125 lbs
58 kg / 127 lbs
59 kg / 130 lbs
60 kg / 132 lbs
61 kg / 134 lbs
62 kg / 136 lbs
63 kg / 138 lbs
64 kg / 141 lbs
65 kg / 143 lbs
66 kg / 145 lbs
67 kg / 147 lbs
68 kg / 149 lbs
69 kg / 152 lbs
70 kg / 154 lbs
71 kg / 156 lbs
72 kg / 158 lbs
73 kg / 160 lbs
74 kg / 163 lbs
75 kg / 165 lbs
76 kg / 167 lbs
77 kg / 169 lbs
78 kg / 171 lbs
79 kg / 174 lbs
80 kg / 176 lbs
81 kg / 178 lbs
82 kg / 180 lbs
83 kg / 183 lbs
84 kg / 185 lbs
85 kg / 187 lbs
86 kg / 189 lbs
87 kg / 191 lbs
88 kg / 194 lbs
89 kg / 196 lbs
90 kg / 198 lbs
91 kg / 200 lbs
92 kg / 202 lbs
93 kg / 205 lbs
94 kg / 207 lbs
95 kg / 209 lbs
96 kg / 211 lbs
97 kg / 213 lbs
98 kg / 216 lbs
99 kg / 218 lbs
100 kg / 220 lbs
101 kg / 222 lbs
102 kg / 224 lbs
103 kg / 227 lbs
104 kg / 229 lbs
105 kg / 231 lbs
106 kg / 233 lbs
107 kg / 235 lbs
108 kg / 238 lbs
109 kg / 240 lbs
110 kg / 242 lbs
111 kg / 244 lbs
112 kg / 246 lbs
113 kg / 249 lbs
114 kg / 251 lbs
115 kg / 253 lbs
116 kg / 255 lbs
117 kg / 257 lbs
118 kg / 260 lbs
119 kg / 262 lbs
120 kg / 264 lbs
121 kg / 266 lbs
122 kg / 269 lbs
123 kg / 271 lbs
124 kg / 273 lbs
125 kg / 275 lbs
126 kg / 277 lbs
127 kg / 280 lbs
128 kg / 282 lbs
129 kg / 284 lbs
130 kg / 286 lbs
131 kg / 288 lbs
132 kg / 291 lbs
133 kg / 293 lbs
134 kg / 295 lbs
135 kg / 297 lbs
136 kg / 299 lbs
137 kg / 302 lbs
138 kg / 304 lbs
139 kg / 306 lbs
140 kg / 308 lbs
141 kg / 310 lbs
142 kg / 313 lbs
143 kg / 315 lbs
144 kg / 317 lbs
145 kg / 319 lbs
146 kg / 321 lbs
147 kg / 324 lbs
148 kg / 326 lbs
149 kg / 328 lbs
150 kg / 330 lbs
151 kg / 332 lbs
152 kg / 335 lbs
153 kg / 337 lbs
154 kg / 339 lbs
155 kg / 341 lbs
156 kg / 343 lbs
157 kg / 346 lbs
158 kg / 348 lbs
159 kg / 350 lbs
160 kg / 352 lbs
161 kg / 355 lbs
162 kg / 357 lbs
163 kg / 359 lbs
164 kg / 361 lbs
165 kg / 363 lbs
166 kg / 366 lbs
167 kg / 368 lbs
168 kg / 370 lbs
169 kg / 372 lbs
170 kg / 374 lbs
171 kg / 377 lbs
172 kg / 379 lbs
173 kg / 381 lbs
174 kg / 383 lbs
175 kg / 385 lbs
176 kg / 388 lbs
177 kg / 390 lbs
178 kg / 392 lbs
179 kg / 394 lbs
180 kg / 396 lbs
181 kg / 399 lbs
182 kg / 401 lbs
183 kg / 403 lbs
184 kg / 405 lbs
185 kg / 407 lbs
186 kg / 410 lbs
187 kg / 412 lbs
188 kg / 414 lbs
189 kg / 416 lbs
190 kg / 418 lbs
191 kg / 421 lbs
192 kg / 423 lbs
193 kg / 425 lbs
194 kg / 427 lbs
195 kg / 429 lbs
196 kg / 432 lbs
197 kg / 434 lbs
198 kg / 436 lbs
199 kg / 438 lbs
200 kg / 441 lbs
201 kg / 443 lbs
202 kg / 445 lbs
203 kg / 447 lbs
204 kg / 449 lbs
205 kg / 452 lbs
206 kg / 454 lbs
207 kg / 456 lbs
208 kg / 458 lbs
209 kg / 460 lbs
210 kg / 463 lbs
211 kg / 465 lbs
212 kg / 467 lbs
213 kg / 469 lbs
214 kg / 471 lbs
215 kg / 474 lbs
216 kg / 476 lbs
217 kg / 478 lbs
218 kg / 480 lbs
219 kg / 482 lbs
220 kg / 485 lbs
221 kg / 487 lbs
222 kg / 489 lbs
223 kg / 491 lbs
224 kg / 493 lbs
225 kg / 496 lbs
226 kg / 498 lbs
227 kg / 500 lbs
228 kg / 502 lbs
229 kg / 504 lbs
230 kg / 507 lbs
231 kg / 509 lbs
232 kg / 511 lbs
233 kg / 513 lbs
234 kg / 515 lbs
235 kg / 518 lbs
236 kg / 520 lbs
237 kg / 522 lbs
238 kg / 524 lbs
239 kg / 526 lbs
240 kg / 529 lbs
241 kg / 531 lbs
242 kg / 533 lbs
243 kg / 535 lbs
244 kg / 538 lbs
245 kg / 540 lbs
246 kg / 542 lbs
247 kg / 544 lbs
248 kg / 546 lbs
249 kg / 549 lbs
250 kg / 551 lbs
251 kg / 553 lbs
252 kg / 555 lbs
253 kg / 557 lbs
254 kg / 560 lbs
255 kg / 562 lbs
256 kg / 564 lbs
257 kg / 566 lbs
258 kg / 568 lbs
259 kg / 571 lbs
260 kg / 573 lbs
261 kg / 575 lbs
262 kg / 577 lbs
263 kg / 579 lbs
264 kg / 582 lbs
265 kg / 584 lbs
266 kg / 586 lbs
267 kg / 588 lbs
268 kg / 590 lbs
269 kg / 593 lbs
270 kg / 595 lbs
271 kg / 597 lbs
272 kg / 599 lbs
273 kg / 601 lbs
274 kg / 604 lbs
275 kg / 606 lbs
276 kg / 608 lbs
277 kg / 610 lbs
278 kg / 612 lbs
279 kg / 615 lbs
280 kg / 617 lbs
281 kg / 619 lbs
282 kg / 621 lbs
283 kg / 624 lbs
284 kg / 626 lbs
285 kg / 628 lbs
286 kg / 630 lbs
287 kg / 632 lbs
288 kg / 635 lbs
289 kg / 637 lbs
290 kg / 639 lbs
291 kg / 641 lbs
292 kg / 643 lbs
293 kg / 646 lbs
294 kg / 648 lbs
295 kg / 650 lbs
296 kg / 652 lbs
297 kg / 654 lbs
298 kg / 657 lbs
299 kg / 659 lbs
300 kg / 661 lbs
Current Medical Conditions - Please list patient's current medical condition(s)
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