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* 1. Subject ID

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* 2. Subject Age (or Date of Birth)

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* 3. Gender

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* 4. Height

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* 5. Weight

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* 6. Length of Residual Limb: (Distance from the proximal joint to the end of the limb):

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* 7. Length of intact limb OR other residual limb (Vertical Length from Greater trochanter to floor):

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* 8. Amputated Side

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* 11. Cause of Amputation

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* 12. Time since First amputation (OR Date of First amputation):

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* 13. Date of Revision amputation (If Applicable):

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* 14. Average Prosthesis use (Hours / day):

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* 15. Average time standing and walking (Hours / day):

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* 16. Profession

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* 17. Prosthetist Name and Phone:

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* 18. Current Prosthesis - (RIGHT side, if applicable)

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* 19. Current Prosthesis - (LEFT side, if applicable)

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* 20. Do you use an Assistive Device indoors?

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* 21. Please specify INDOOR assistive device use

  Never Some of the time Most of the time Always
Wheelchair
Walker
Crutches
Cane

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* 22. Do you use an Assistive Device OUTDOORS?

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* 23. Please specify OUTDOOR assistive device use

  Never Some of the time Most of the time Always
Wheelchair
Walker
Crutches
Cane

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* 24. Functional Co-morbidity Index

How severaly does the following medical condition affect the subject's daily functioning?

  NO influence on function  PARTIAL influence on function SEVERELY affects function
Rheumatoid Arthritis and/or Osteoarthritis
Osteoporosis and/or fractures
Degenerative disc disease
(e.g. back disease, spinal stenosis, or severe chronic back pain)
COPD, Asthma, emphysema, or other pulmonary disease
Angina pectoris
Myocardial Infarction
Heart failure
Any disease causing heart failure e.g. atrial fibrillation or valve problems
Neurological disease
(e.g. multiple sclerosis, Parkinson's disease)
Dementia or other neurocognitive disorder
Cerebrovascular accident (stroke)
Preipheral vascular disease
Diabetes mellitus (Type I or II)
Gastrointestinal disease
Obesity and/or BMI > 30?
(BMI = [ Weight (in kg) ] / [ height (in meter) ] ^ 2
Depression
(or other psychiatric diagnoses causing mood disturbances, e.g. Bipolar disorder)
Anxiety or panic disorder
Visual impairments
(e.g. cataracts, glaucoma, macular degeneration)
Hearing impairment
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