Mobility Questionnaire
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1. Mobility Preferences

Thank you for participating in the Mobility Questionnaire. Your feedback is critical to understanding the mobility needs and preferences of amputees. This brief survey should only take approximately five minutes of your time.
All the information you provide will be kept strictly confidential. The results will be reported in summary form only so no individual who completed it can be identified.

1. Which of the following prosthetic or assistive devices do you currently use most?

Which of the following prosthetic or assistive devices do you currently use most? Traditional prosthetic device

Crutches

Walker

LEGSIM

Other (please specify)

2. On average, how many hours per day do you use your primary prosthetic/ assistive device?

On average, how many hours per day do you use your primary prosthetic/ assistive device? Hours

3. On average, how many hours per day do you move around without the assistance of your primary prosthetic/ assistive device?

On average, how many hours per day do you move around without the assistance of your primary prosthetic/ assistive device? Hours

4. Which of the following prosthetic/assistive devices do you use to move around when you are not wearing your primary device? (Check all that apply)

Which of the following prosthetic/assistive devices do you use to move around when you are not wearing your primary device? (Check all that apply) Crutches

Wheelchair