Thank you for participating in this survey. 

The purpose of this survey is to collect information from many people with amputations over a period of time to see how well the group performs certain "Activities of Daily Living" (ADLs), and also to see if improvements are made over time. We do not need to know your name and will NEVER sell, give away or in any way share your personal data with anyone without your specific authorization.  We also will NOT send you any correspondence unless you specifically authorize us to do so. 

It is important that we match each person's responses over time to the same person, but we do not need to know your name and we will never sell or give away your personal information. We will not send you any correspondence unless you specifically authorize it.

Some very basic information is required in order for us properly compare the results.We appreciate your willingness to help identify opportunities to improve the level of care available to persons with amputations.

Let me know if you have any questions on this survey.

Scott Williamson
1.
In what country do you live?
2.
If you live in the United States, in what state do you live?
3.
In what city/town do you usually see your prosthetist?
4.
Please tell us a little about your prosthetist:
Company Name
Usual Prosthetist's Name
Company Address
5.
Please tell us about yourself.
Email:
Gender
Birth Date:
Race
Weight: (in pounds)
Height (in inches)
6.
Please indicate any other conditions you have:

 
7.
With respect to your history of smoking, which response is most accurate:
 0%