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Patient Satisfaction Survey

Please complete this survey after receiving your orthosis/prosthesis, please mark the reponse that most closely reflects your opinion.

1. My prosthesis/orthosis fits well
2. The weight of my prosthesis/orthosis is manageable
3. My prosthesis/orthosis is comfortable through the day
4. It is easy to put on my prosthesis/orthosis
5. My prosthesis/orthosis looks good
6. My prosthesis/orthosis is durable
7. My clothes are free of wear and tear from my prosthesis/orthosis
8. My skin is free of abrasions and irritations
9. My prosthesis/orthosis is pain free to wear
10. I can afford the out-of-pocket expenses to purchase and maintain my prosthesis/orthosis
11. I can afford to repair or replace my prosthesis/orthosis as soon as needed
12. I received an appointment with a prosthesist/orthosist within a reasonable amount of time
13. I was shown the proper level of courtesy and respect by the staff
14. I waited a reasonable amount of time to be seen
15. Clinic staff fully informed me about equipment choices
16. The prosthesist/orthosist gave me the opportunity to express my concerns regarding my equipment
17. The prosthesist/orthotist was responsive to my concerns and questions
18. I am satisfied with the training I received in the use and maintenance of my prosthesis/orthosis
19. The prosthetist/orthotist discussed problems I might encounter with my equipment
20. The staff coordinated their services with my therapists and doctors
21. I was a partner in decision-making with clinic staff regarding my care and equipment
I certify that I am the person listed above and completed this survey
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