Self-Evaluation Form

If you have questions or concerns about the appropriateness of the orthosis or prosthesis you are currently wearing, and would like to receive a free, no-obligation review from one of our staff of experienced and credentialed practitioners, please fill out the form below. Your answers to the questions below will guide our clinical specialists in assessing your situation and determining whether an alternative or updated solution might better suit your individual needs.

A staff specialist will contact you to discuss your case in greater detail and offer recommendations or suggestions, as appropriate. An appointment to meet in person would naturally offer our practitioner a clearer understanding of your situation and better opportunity for customized assessment.

Please let us know when and where we may contact you to discuss your case, your questions, and your needs, by including your e-mail address. phone number, and preferred time to call.

Your Name

Daytime Telephone

Hours available to receive call

Email Address

PROSTHESIS WEARERS:

1) Do you feel you can do most things with a prosthesis that can be done with a normal arm/leg?

Yes

No

Not Applicable

2) Do you feel that you have a good understanding of prosthetics?

Yes

No

Not Applicable

3) On a scale of 1 to 5, with 5 being very comfortable, how would you rate your prosthesis?

1

2

3

4

5

Not Applicable

4) One a scale of 1 to 5, with 5 being very important, how important is your prosthesis to you?

1

2

3

4

5

Not Applicable

5) Is your prosthesis absolutely necessary to your lifestyle?

Yes

No

Not Applicable

6) Have you received training that has or will allow you to accomplish your goals with your prosthesis?

Yes

No

Not Applicable

7) Does your prosthesis feel so heavy that it wears you out to use it during the day?

Yes

No

Not Applicable

8) Do you use your prosthesis effectively, without any problems?

Yes

No

Not Applicable

9) Does it break down often?

Yes

No

Not Applicable

10) How does your prosthesis compare to a normal limb?

11) On a scale of 1 to 5, with 5 being very difficult, how difficult is your prosthesis to put on and remove?

1

2

3

4

5

Not Applicable

ORTHOSIS WEARERS:

12) What type of orthosis are you currently wearing, and for what condition was it prescribed or recommended?

13) How long have you been wearing it?

14) Does your orthosis allow you to function normally/effectively in most life situations?

Yes

No

Not Applicable

15) Do you have a good understanding of orthotics, and the principles that make braces effective devices?

Yes

No

Not Applicable

16) On a scale of 1 to 5, with 5 being very comfortable, how would you rate your orthosis?

1

2

3

4

5

Not Applicable

17) One a scale of 1 to 5, with 5 being very important, how important is your orthosis to you?

1

2

3

4

5

Not Applicable

18) Is your orthosis absolutely necessary to your lifestyle?

Yes

No

Not Applicable

19) Do you have any problems with the fit or function of your orthosis?

Yes

No

Not Applicable

20) Does it need frequent adjustment or refitting?

Yes

No

Not Applicable

21) On a scale of 1 to 5, with 5 being very difficult, how difficult is your orthosis to put on and remove?

1

2

3

4

5

Not Applicable