K-Level Questionnaire Algorithm Question Title * 1. NAME and/or ID Question Title * 2. Do you expect the patient to reach a defined functional state within 1 year from today? YES NO Question Title * 3. Is the patient motivated to ambulate with a prosthesis following amputation? YES NO Question Title * 4. Does the patient have the cognitive ability to understand and follow directions for ambulatory prosthetic use? YES NO Question Title * 5. Is the patient free of wounds (other than amputation incision) that would prevent ambulatory prosthetic fitting? YES NO Question Title * 6. Is the patient healed from the amputation surgery to proceed to ambulatory prosthetic fitting? YES NO Question Title * 7. Is the patient free of residual limb pain that would prevent ambulatory prosthetic fitting? YES NO Question Title * 8. Is the patient free from smoking or a disease process from smoking that may impede their ability to ambulate? YES NO Question Title * 9. Does the patient have muscle strength within normal limits in their upper extremities bilaterally and contralateral lower extremity to allow for ambulation? YES NO Question Title * 10. Is the patient free of arthritis (on sound limb or on remaining joints of amputated limb) that might prevent ambulation? YES NO Question Title * 11. Is the patient free of congestive heart failure (CHF) that would prevent ambulation? YES NO Question Title * 12. Is the patient free of cardiovascular disease (CAD, PVD, CVI) in opposite lower extremity that would prevent ambulation? YES NO Question Title * 13. Does the patient have range of motion within normal limits in their upper extremities bilaterally and contralateral lower extremity to allow for ambulation? YES NO Question Title * 14. Is the patient free of any neurological disorders and/or symptoms that would prevent ambulation? YES NO Question Title * 15. Is the patient free of medication side effects that would affect balance and/or ambulation? YES NO Question Title * 16. Does the patient have an obesity BMI classification of severe obesity or higher that would affect prosthetic fit and/or ambulation? YES NO Question Title * 17. Is the patient knowingly compliant with the caring physicians’ orders? YES NO Question Title * 18. Is the patient free of 2 or more co-morbidities? YES NO Question Title * 19. Is the patient younger than 80 years old? YES NO Question Title * 20. Is the patient currently employed full time or part time? (work that includes pay reports and W2 forms? YES NO Question Title * 21. Is the patient currently a student or do they engage in volunteer activities within their community? YES NO Question Title * 22. Did the patient perform ADL’s Independently or Independently modified prior to the amputation? YES NO Question Title * 23. Did the patient walk withOUT an assistive device prior to the amputation? YES NO Done