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

First name

Last name

I certify that I am the person listed above and completed this survey

Yes