Pants Up Easy Short Needs Assessment
  • What type of participant are you?
  • Which Product(s) Would Be Best For You?
    (Financing Available for as low as $20.00 per month)
    • Wall Mount
    • Toilet Model
    • Wheelchair Model
    • 3 in 1 Travel Model with Case
    • *
      First Name
    • *
      Last Name
    • *
    • *
  • What are the realized benefits you see from using Pants Up Easy?
  • Where would you use your Pants Up Easy System?
  • What is your height?
  • Choose your weight
  • Do you have use of your arms and hands?
  • How is your upper body strength?
  • What type of Disability do you have? (Please check all that apply)
  • Mobility tools used? ( Please check all that apply)
  • Housing
  • Employment Status (Please check all that apply)
  • Income Range
  • Are you a Veteran?
  • Type of Insurance? (Please check all that apply)
  • What methods are best for you to acquire your Pants Up Easy System?
    (Check all that apply)
  • You can upload pictures of your installation location for the Toilet Model, Height of toilet tank, height of shoulder sitting up as straight as possible on the toilet, and or wheelchair?
    No file selected
  • ZS_Email_Address

That's all, folks!

* End page and disqualification logic can only be seen in the live survey