Note: For the questions below, the term "physical condition" refers to the reason you use an orthotic or prosthetic device.

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* 1. Name and/or ID

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* 2. How much do you keep to yourself to avoid people's reactions to a missing body part or your need for a device?

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* 3. To what extent do you find that people's attitudes toward your physical condition are insulting?

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* 4. To what extent are you prevented from doing what you want to do because of social attitudes, the law, or environmental barriers?

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* 5. How much does pain interfere with your activities (including both work outside the home and household duties)?

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* 6. To what extent do you accomplish less than you would like because of your physical condition?

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* 7. To what extent do you accomplish less than you would like because of emotional problems?

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* 8. How much does your physical condition restrict your ability to run errands?

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* 9. How much does your physical condition restrict your ability to pursue a hobby?

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* 10. How much does your physical condition restrict your ability to do chores?

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* 11. How much does your physical condition restrict your ability to do paid work?

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* 12. To what extent have you cut down on work or other activities because of your physical condition?

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* 13. To what extent have you cut down on work or other activities because of emotional problems?

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