Prosthesis Evaluation Questionnaire

Group 1

These first questions are about YOUR PROSTHESIS.

Question Title

* 1. Name and/or ID

Question Title

* 2. Over the past four weeks, rate how happy you have been with your current prosthesis.

EXTREMELY UNHAPPY

EXTREMELY HAPPY

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 3. Over the past four weeks, rate the fit of your prosthesis.

TERRIBLE

EXCELLENT

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 4. Over the past four weeks, rate the weight of your prosthesis.

TERRIBLE

EXCELLENT

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 5. Over the past four weeks, rate your comfort while standing when using your prosthesis.

TERRIBLE

EXCELLENT

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 6. Over the past four weeks, rate your comfort while sitting when using your prosthesis.

TERRIBLE

EXCELLENT

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 7. Over the past four week, rate how often you felt off balance while using your prosthesis.

ALL THE TIME

NOT AT ALL

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 8. Over the past four weeks, rate how much energy it took to use your prosthesis for as long as you needed it.

COMPLETELY EXHAUSTING

NONE AT ALL

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 9. Over the past four weeks, rate the feel (such as the temperature and texture) of the prosthesis (sock, liner, socket) on your residual limb (stump).

WORST POSSIBLE

BEST POSSIBLE

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 10. Over the past four weeks, rate the ease of putting on (donning) your prosthesis.

TERRIBLE

EXCELLENT

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 11. Over the past four weeks, rate how your prosthesis has looked.

TERRIBLE

EXCELLENT

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 12. Over the past four weeks, rate how often your prosthesis made squeaking, clicking, or belching sounds.

ALWAYS

NEVER

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 13. If it made any sounds in the past four weeks, rate how bothersome these sounds were to you.

EXTREMELY BOTHERSOME

NOT AT ALL

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 14. Over the past four weeks, rate the damage done to your clothing by your prosthesis.

EXTENSIVE DAMAGE

NONE

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 15. Over the past four weeks, rate the damage done to your prosthesis cover.

EXTENSIVE DAMAGE

NONE

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 16. Over the past four weeks, rate your ability to wear the shoes (different heights, styles) you prefer.

CANNOT

NO PROBLEM

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 17. Over the past four weeks, rate how limited your choice of clothing was because of your prosthesis.

WORST POSSIBLE

NOT AT ALL

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 18. Over the past four weeks, rate how much you sweat inside your prosthesis (in the sock, liner, socket).

EXTREME AMOUNT

NOT AT ALL

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 19. Over the past four weeks, rate how smelly your prosthesis was at its worst.

EXTREMELY SMELLY

NOT AT ALL

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 20. Over the past four weeks, rate how much of the time your residual limb was swollen to the point of changing the fit of your prosthesis.

ALL THE TIME

NEVER

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 21. Over the past four weeks, rate any rash(es) that you got on your residual limb.

EXTREMELY BOTHERSOME

NOT AT ALL

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 22. Over the past four weeks, rate any ingrown hairs (pimples) that were on your residual limb.

EXTREMELY BOTHERSOME

NOT AT ALL

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 23. Over the past four weeks, rate any blisters or sores that you got on your residual limb.

EXTREMELY BOTHERSOME

NOT AT ALL

Clear

i We adjusted the number you entered based on the slider’s scale.