This is a questionnaire designed to investigate different aspects of having a prosthesis. Please answer every item as honestly as you can. There are no right or wrong answers. Your responses will remain confidential.

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* 1. Name and/or ID

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* 2. Client date of birth:

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* 3. Are you:

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* 4. How long ago did you have your amputation?

(If you have had more than one amputation surgery please refer to your first amputation surgery)

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* 5. How long have you had a prosthesis?

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* 6. How long have you had the prosthesis that you wear at he moment?

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* 7. What type of prosthesis do you have?

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* 8. What was your amputation a result of?

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