AMT Traditional G-Tube Evaluation Survey 2026

Product Evaluation Form

Thank you for providing feedback on one of the AMT Traditional G-Tube products (Capsule Dome, Balloon G-Tube, or Capsule Monarch). Please complete one (1) copy of the Evaluation Survey (if you are a caregiver for multiple patients, please complete one (1) survey for each participant in your care).

Answer each question to the best of your ability. If a question or statement doesn't apply to your experience with a Traditional G-Tube, you can select "N/A". Please be sure to provide us your AMT device lot number and AMT device part number. Please see example images for where to find this information.

As a thank you for your feedback, you'll have the opportunity to enter a Giveaway at the bottom of this survey.

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AMT Traditional Length G-Tube Family

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* 1. Evaluation Survey Participant:

End-User (select this option if you use the AMT Traditional G-Tube)

Caregiver (select this option if you provide care for someone who uses the AMT Traditional G-Tube)

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* 2. Participant Information

Name:

Age of person who is using the G-Tube:

Date Survey was Completed:

Your own AMT Device REF (Part Number) - see example image below on where to find this information:

Your own AMT Device Lot Number - see example image below on where to find this information:

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Example of where to find your AMT device Lot Number and Part Number on product label:

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* 3. I currently use the following AMT Traditional/ Standard Length G-Tube product (select one):

AMT Balloon G-Tube

AMT Capsule Monarch® G-Tube

AMT Capsule Dome G-Tube

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* 4. The AMT Traditional G-Tube is in place for the following length of time:

< 1 month

1 - 3 months

3 - 6 months

> 6 months

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* 5. If using the AMT Traditional Length Balloon G-Tube - I exchange my Balloon G-Tube at home:

Yes

N/A

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* 6. If using the AMT Capsule Monarch® or Capsule Dome - I exchange my Non-Balloon G-Tube at home:

Yes

N/A

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* 7. Please indicate your your satisfaction with the following safety and performance features:

	Very Dissatisfied	Dissatisfied	OK	Satisfied	Very Satisfied	N/A
Device Stability within the Stoma	Device Stability within the Stoma Very Dissatisfied	Device Stability within the Stoma Dissatisfied	Device Stability within the Stoma OK	Device Stability within the Stoma Satisfied	Device Stability within the Stoma Very Satisfied	Device Stability within the Stoma N/A
Ease of Feeding	Ease of Feeding Very Dissatisfied	Ease of Feeding Dissatisfied	Ease of Feeding OK	Ease of Feeding Satisfied	Ease of Feeding Very Satisfied	Ease of Feeding N/A
Ease of Medication Delivery	Ease of Medication Delivery Very Dissatisfied	Ease of Medication Delivery Dissatisfied	Ease of Medication Delivery OK	Ease of Medication Delivery Satisfied	Ease of Medication Delivery Very Satisfied	Ease of Medication Delivery N/A
Ease of Decompression	Ease of Decompression Very Dissatisfied	Ease of Decompression Dissatisfied	Ease of Decompression OK	Ease of Decompression Satisfied	Ease of Decompression Very Satisfied	Ease of Decompression N/A
Device Longevity	Device Longevity Very Dissatisfied	Device Longevity Dissatisfied	Device Longevity OK	Device Longevity Satisfied	Device Longevity Very Satisfied	Device Longevity N/A

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* 8. Please indicate the degree to which you agree or disagree with each statement below:

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree	N/A
Using the AMT Traditional G-Tube is easy and intuitive.	Using the AMT Traditional G-Tube is easy and intuitive. Strongly Disagree	Using the AMT Traditional G-Tube is easy and intuitive. Disagree	Using the AMT Traditional G-Tube is easy and intuitive. Neutral	Using the AMT Traditional G-Tube is easy and intuitive. Agree	Using the AMT Traditional G-Tube is easy and intuitive. Strongly Agree	Using the AMT Traditional G-Tube is easy and intuitive. N/A
The AMT Traditional G-Tube is safe to use for my/my child's enteral nutrition needs.	The AMT Traditional G-Tube is safe to use for my/my child's enteral nutrition needs. Strongly Disagree	The AMT Traditional G-Tube is safe to use for my/my child's enteral nutrition needs. Disagree	The AMT Traditional G-Tube is safe to use for my/my child's enteral nutrition needs. Neutral	The AMT Traditional G-Tube is safe to use for my/my child's enteral nutrition needs. Agree	The AMT Traditional G-Tube is safe to use for my/my child's enteral nutrition needs. Strongly Agree	The AMT Traditional G-Tube is safe to use for my/my child's enteral nutrition needs. N/A
I have not experienced any negative side effects while using the AMT Traditional G-Tube.	I have not experienced any negative side effects while using the AMT Traditional G-Tube. Strongly Disagree	I have not experienced any negative side effects while using the AMT Traditional G-Tube. Disagree	I have not experienced any negative side effects while using the AMT Traditional G-Tube. Neutral	I have not experienced any negative side effects while using the AMT Traditional G-Tube. Agree	I have not experienced any negative side effects while using the AMT Traditional G-Tube. Strongly Agree	I have not experienced any negative side effects while using the AMT Traditional G-Tube. N/A
The design of my/my child's AMT G-Tube helps reduce skin irritation.	The design of my/my child's AMT G-Tube helps reduce skin irritation. Strongly Disagree	The design of my/my child's AMT G-Tube helps reduce skin irritation. Disagree	The design of my/my child's AMT G-Tube helps reduce skin irritation. Neutral	The design of my/my child's AMT G-Tube helps reduce skin irritation. Agree	The design of my/my child's AMT G-Tube helps reduce skin irritation. Strongly Agree	The design of my/my child's AMT G-Tube helps reduce skin irritation. N/A
Use of my/my child's AMT product has improved my/my child's quality of life.	Use of my/my child's AMT product has improved my/my child's quality of life. Strongly Disagree	Use of my/my child's AMT product has improved my/my child's quality of life. Disagree	Use of my/my child's AMT product has improved my/my child's quality of life. Neutral	Use of my/my child's AMT product has improved my/my child's quality of life. Agree	Use of my/my child's AMT product has improved my/my child's quality of life. Strongly Agree	Use of my/my child's AMT product has improved my/my child's quality of life. N/A
The adjustable external bolster helps accommodate my/my child's various sizing needs.	The adjustable external bolster helps accommodate my/my child's various sizing needs. Strongly Disagree	The adjustable external bolster helps accommodate my/my child's various sizing needs. Disagree	The adjustable external bolster helps accommodate my/my child's various sizing needs. Neutral	The adjustable external bolster helps accommodate my/my child's various sizing needs. Agree	The adjustable external bolster helps accommodate my/my child's various sizing needs. Strongly Agree	The adjustable external bolster helps accommodate my/my child's various sizing needs. N/A

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* 9. If using a Capsule G-Tube, please indicate the degree to which you agree or disagree with each statement below:

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree	N/A
The capsule device is ideal for my/my child due to my/my child's anatomy or difference in gastric environment	The capsule device is ideal for my/my child due to my/my child's anatomy or difference in gastric environment Strongly Disagree	The capsule device is ideal for my/my child due to my/my child's anatomy or difference in gastric environment Disagree	The capsule device is ideal for my/my child due to my/my child's anatomy or difference in gastric environment Neutral	The capsule device is ideal for my/my child due to my/my child's anatomy or difference in gastric environment Agree	The capsule device is ideal for my/my child due to my/my child's anatomy or difference in gastric environment Strongly Agree	The capsule device is ideal for my/my child due to my/my child's anatomy or difference in gastric environment N/A
The encapsulated bolster reduces pain during insertion	The encapsulated bolster reduces pain during insertion Strongly Disagree	The encapsulated bolster reduces pain during insertion Disagree	The encapsulated bolster reduces pain during insertion Neutral	The encapsulated bolster reduces pain during insertion Agree	The encapsulated bolster reduces pain during insertion Strongly Agree	The encapsulated bolster reduces pain during insertion N/A

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* 10. General comments/suggestions:

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* 11. How likely is it that you would recommend the selected device to a friend or colleague?

Not at all likely

Extremely likely

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* 12. I would like to enter to win a $25 Amazon® eGift Card. Being named a Winner is conditional upon AMT's verification of the entrant's AMT Traditional Length Balloon G-Tube, Capsule Monarch® G-Tube, or Capsule Dome G-Tube. Must be 18 years of age or older and legal resident of the 50 United States or District of Columbia to enter.

Yes

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* 13. If you selected "Yes" for the question above, please enter your contact information. I understand that if I did not provide the Device Lot Number in Question 2, I may be contacted for verification of the AMT device for which I am providing feedback. Valid lot numbers and part numbers help verify your survey.

Participant's Full Name

State

Country of Residence

Email Address

Phone Number

The Health Insurance Portability and Accountability Act (“HIPAA”) requires an individual to specifically consent and authorize the use of protected health information (“PHI”) before the information is used outside of providing healthcare to the individual. By agreeing below I consent to and authorize Applied Medical Technology (“AMT”), its employees, affiliates, and agents to use the PHI.

I understand that:

PHI used or disclosed pursuant to this authorization may be re-disclosed by the recipient and its confidentiality may no longer be protected by federal or state law
I have the right to revoke this authorization and future use of the PHI by providing written notice to AMT
Once AMT uses the PHI I cannot revoke authorization for that use
My treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I sign this form
I have the right to refuse to sign this authorization
I provide this authorization as a voluntary contribution and hereby release and discharge AMT from all claims to copyright ownership, payment, or other rights that I may have with respect to the PHI

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* 14. I certify that I am 18 years of age or older, I have read the above HIPAA Release of Information, and I fully understand its terms. If completing this survey on behalf of a minor, I represent that I am the parent or legal guardian of the minor and represent that I am authorized to respond on the minor’s behalf. Clicking "Yes" below will serve as an electronic signature; I intend to be bound by my electronic signature.

Yes

Thank You for Your Evaluation

Applied Medical Technology, Inc. (AMT)

8006 Katherine Blvd., Brecksville, OH 44141

P: 440-717-4000 / 800-869-7382

F: 440-717-4220

E: CS@AppliedMedical.net

We are committed to keeping your email address confidential. We do not sell, rent, or lease our subscription lists to third parties, and we will not provide your personal information to any third party individual, government agency, or company at any time.

Official Giveaway Rules apply. Participants must complete all required fields of the entry form with information that is valid to be eligible. Prizes will be awarded to the first fifteen (15) eligible entrants, under the condition that the Sponsor is able to verify entrants' use of the AMT Traditional Length G-Tube product for which feedback is given. Giveaway closes on November 30, 2026 at 11:59 PM EST. Full Giveaway rules can be found at https://www.appliedmedical.net/legal/official-rules-and-regulations/