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Transtibial Prosthetic Research
1.
Do you give your consent to have your answers recorded and compiled for the purposes of designing a new prosthetic? (All responses will be recorded as anonymous)
Yes
No
2.
What caused the need for your amputation?
Trauma
Vascular Disease
Diabetes
Other (please specify)
3.
What type of Suspension system do you use?
Pin lock system
Suction suspension
Vacuum suspension
Sleeve Suspension
Cuff,strap,or belt
Other (please specify)
4.
What type of Socket do you use?
Patellar tendon bearing
Total surface bearing
Hybrid
Other (please specify)
5.
What type of Foot do you use?
Solid Ankle Cushion Heel (SACH)
Elastic Keel Foot
Single-Axis
Multi-Axis
Dynamic Response
Other (please specify)
6.
Are you satisfied with your prosthetics aesthetic?
No it makes me uncomfortable.
Its not great but not the worst either.
It works perfectly for me.
Other (please specify)
7.
What sports or physically-intensive hobbies do you participate in?
8.
How active are you? (activity level on average per week)
Exercise 5-7 times a week
Exercise 3-5 times a week
Exercise 1-3 times a week
Stay active through work or chores/errands
9.
What demands did your occupation have pre-amputation?
Physically Intensive work
It was mainly desk work
Hybrid of both
Other (please specify)
10.
Are you still in that line of work?
Yes
No