Exit Wheelchair user survey Question Title * 1. Name Question Title * 2. Age group, male/ female, ability level/ diagnosis Question Title * 3. Current make of wheelchair Question Title * 4. Do you have difficulty when transferring from or to your wheelchair to a bed, chair, toilet? Yes No Other (please specify) Question Title * 5. Have you ever fallen onto the floor – how often might this happen daily weekly once a month never Question Title * 6. What do you do when it happens? – please describe, i.e., call for help, pull yourself back up Question Title * 7. What are the consequences for you and others when this happens? Question Title * 8. If there was a way to more easily get yourself back up onto your wheelchair would you be interested in buying this solution for yourself? Yes No Question Title * 9. How much would you pay? 500-1000 1000-1500 2000-2500 Other (please specify) Question Title * 10. We are going to try and design an easier way to get back into your wheelchair and would you be happy if we contact you again at a later stage to get some feedback on our solution as we design and develop it? Name Country Email Address Phone Number Done