Access to Work Seating Assessment Form

We can recommend a chair based on the following information. Please fill out this form and we will get back to you asap with suggestions. Alternatively, give us a call and we can help you over the phone.

Your Details

Your Name *

Who Were You Referred by? *

Access to Work Reference Number *

Your Phone Number

Your Email *

Delivery Address *

Symptoms

Please enter brief details of current conditions, symptoms, and area of pain & discomfort.

Your Dimensions

Weight (stones/kilos) *

Height (feet and inches) *

Please enter the following dimensions, related to the below image

A. Floor to behind (underside) knee (mm) *

B. Back of Bum to behind (under side) knee (mm) *

(Back of bum is closest point to back rest)

C. Seat Pad to Top of Shoulder (mm) *

(To obtain back length without including neck)

D. Hip to Hip (mm) *

(Pocket to Pocket if wearing trousers)

E. Shoulder Width (mm)

(Outside to Outside of each shoulder)

F. Elbow to Top of Seat (mm)

(Don’t rest against desk, relaxed shoulders and elbow bent to 90-degree angle)

G. Desk Height (mm)

(Floor to top side of desk)

Chair Requirements

Chair Options (please tick all required)

Headrest
Lumbar Support - (provides adjustable support in the small of your back)
Thoracic Support - (provides support to the entire spinal length including upper back)
Air Core Seat - (improves sitting comfort and relieves pressure on the buttocks)

Would you like arms on the chair?

Floor Type

Desk Shape

Are your feet flat on the floor when elbows are level with the desk?

Can you maintain a neutral head position (looking straight forward) whilst looking at your screen(s)?

Do you have any issues using your mouse and/or keyboard?

Have you been advised by your case manager to look at other products such as a desk, footrest, lumbar supports or any desktop accessories?

Name

Access to Work Seating Assessment Form

Your Details

Your Dimensions

Please enter the following dimensions, related to the below image

Chair Requirements

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