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May Quick Survey on Patient Safety
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1.
What type of wheelchair do you use for everyday mobility?
(Required.)
Manual chair
Power chair
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2.
Do you use the seatbelt in your wheelchair?
(Required.)
All the time
Most of the time
Sometimes
Never
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3.
Do you feel that you know your capabilities and limitations in a wheelchair?
(Required.)
Yes
No
Comment:
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4.
Do you feel that you take appropriate safety measures to avoid injury when completing activities of daily living (ADLs)?
(Required.)
All the time
Most of the time
Sometimes
Never
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5.
Do you feel that you have the necessary equipment to help you perform ADLs safely?
(Required.)
Yes
No
I don’t need any equipment to assist me to perform ADLs safely
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6.
Gender:
(Required.)
Male
Female
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7.
What is your age?
(Required.)
Under 25
26-35
36-45
46-55
56-65
66 or over
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8.
Years post injury?
(Required.)
<1
1-2
3-5
6-10
11-15
16-20
21-25
>25
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9.
Level of Injury:
(Required.)
Paraplegia
Tetraplegia