Subject Demographic Information

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* 1. Subject ID

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* 2. Subject Age (or Date of Birth)

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* 3. Gender

Male

Female

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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

Left

Right

Bilateral

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* 9. Level of Amputation (RIGHT Limb, If applicable)

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* 10. Level of Amputation (LEFT Limb, if applicable)

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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)

Socket Design

Suspension

Prosthetic Foot/Ankle

Prosthetic Knee

Other components, such as shock absorber, torsion adapter etc.

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

Socket Design

Suspension

Prosthetic Foot/Ankle

Prosthetic Knee

Other components, such as shock absorber, torsion adapter etc.

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* 20. Do you use an Assistive Device indoors?

Yes

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* 21. Please specify INDOOR assistive device use

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

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* 22. Do you use an Assistive Device OUTDOORS?

Yes

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* 23. Please specify OUTDOOR assistive device use

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

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

Subject Demographic Information

Question Title

* 1. Subject ID

Question Title

* 2. Subject Age (or Date of Birth)

Question Title

* 3. Gender

Question Title

* 4. Height

Question Title

* 5. Weight

Question Title

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

Question Title

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

Question Title

* 8. Amputated Side

Question Title

* 9. Level of Amputation (RIGHT Limb, If applicable)

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* 10. Level of Amputation (LEFT Limb, if applicable)

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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):

Question Title

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

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

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* 16. Profession

Question Title

* 17. Prosthetist Name and Phone:

Question Title

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

Question Title

* 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

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* 22. Do you use an Assistive Device OUTDOORS?

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* 23. Please specify OUTDOOR assistive device use

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* 24. Functional Co-morbidity IndexHow severaly does the following medical condition affect the subject's daily functioning?

* 24. Functional Co-morbidity Index

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