Skip to content
April Quick Survey on Wheelchair Related Injuries
*
1.
What kind of wheelchair do you use for everyday mobility?
(Required.)
Manual chair
Power chair
*
2.
Have you ever fallen out of the wheelchair without getting injured?
(Required.)
Yes
No
*
3.
If yes, how many times do you think that has happened?
(Required.)
1
2-3
4-5
More than 5 times
*
4.
Have you even been injured from falling out of the wheelchair?
(Required.)
Yes
No
*
5.
If yes, how many times do you think that has happened?
(Required.)
1
2-3
4-5
More than 5 times
*
6.
If yes, did it require you to go to the ER/ seek medical attention?
(Required.)
Yes, I had to go to the ER right after my fall
Yes, I had to seek medical attention within 24 hrs of my fall
Yes, I had to seek medical attention within 72 hrs of my fall
Yes, I had to seek medical attention
No
*
7.
If yes, did you sustain any long lasting injuries that affected your daily life?
(Required.)
Yes
No
Comment:
*
8.
Gender:
(Required.)
Male
Female
*
9.
What is your age?
(Required.)
Under 25
26-35
36-45
46-55
56-65
66 or over
*
10.
Years post injury?
(Required.)
<1
1-2
3-5
6-10
11-15
16-20
21-25
>25
*
11.
Level of Injury:
(Required.)
Paraplegia
Tetraplegia