Customer survey

Delivery

This information helps us measure the impact the Slingshot Socket™ has on quality of life, by comparing your recent fitting to your pre-existing socket. 3-5 Minutes to complete

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Step 1 of 11

Phone

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Order Number # (if available)

Name*

First Last

Email*

Phone*

Practitioner’s Name

Clinic Name

What is your amputation level (related to this fitting)?*

Below Knee

Above Knee

Symes

Knee Disarticulation

Below Elbow

Above Elbow

Hip Disarticulation/Hemipelvectomy

Shoulder Disarticulation/Forequarter

Other

What is your current weight (in pounds)?*

Current socket

Which type of socket were you fit with?

Conventional Socket

Slingshot Socket™, but I’m not sure which one

Slingshot Socket Fission™

Slingshot Socket Sling™

Slingshot Socket™, Hip Disarticulation

Slingshot Socket Fussion™

Slingshot Socket™, Upper Extremity

How would you rate the weight of your new prosthesis? (0 = Lightweight —> 10 = Heavy)

0	1	2	3	4	5	6	7	8	9	10

(0 = Lightweight —> 10 = Heavy)

Phantom Pain and Limb Health

In your new socket, have you experienced a change in frequency or severity of phantom limb pain? (0 = Less Phantom Limb Pain —> 5 = No change —> 10 = Worse Phantom Limb Pain)

0	1	2	3	4	5	6	7	8	9	10

(0 = Less Phantom Limb Pain —> 5 = No change —> 10 = Worse Phantom Limb Pain)

In your new socket, how much do you feel you use your residual limb muscles? (0 = Not at all —> 10 = I feel my limb muscle firing as I’m walking)

0	1	2	3	4	5	6	7	8	9	10

(0 = Not at all —> 10 = I feel my limb muscle firing as I’m walking)

Activity Level

How many hours do you anticipate you will be able to wear your new prosthesis on an average day?

1-2 hours / day

2-4 hours / day

5-6 hours / day

7-8 hours / day

9-10 hours / day

11-12 hours / day

13-14 hours / day

15-16+ hours / day

I do not current wear a prosthesis

How would you rate how active you are able to be? (0 = My activity level is limited by my socket —> 10 = Unlimited with my socket)

0	1	2	3	4	5	6	7	8	9	10

(0 = My activity level will be limited by my socket —> 10 = Unlimited with my new socket)

Stability and Ambulation Confidence

When walking indoors with your prosthesis, do you…

Use a wheelchair

Use a walker

Use one cane or one crutch

No assistive devices used

Use two canes or two crutches

When walking outside wearing your prosthesis, do you…

Use a wheelchair

Use a walker

Use one cane or one crutch

No assistive devices used

Use two canes or two crutches

How would you rate your feeling of stability when walking on your current socket? (0 = Very unstable —> 10 = Very stable)

0	1	2	3	4	5	6	7	8	9	10

(0 = Very unstable —> 10 = Very stable)

How would you rate your feeling of having good control of your prosthetic? (0 = It feels like a dead weight hanging off of me —> 10 = It feels like an extension of my own leg)

0	1	2	3	4	5	6	7	8	9	10

(0 = It feels like a dead weight hanging off of me —> 10 = It feels like an extension of my own leg)

Volume Management

How important is faster, simpler, socket adjustability to you? (0 = Unimportant —-> 10 = Very Important)

0	1	2	3	4	5	6	7	8	9	10

(0 = Much Simpler to adjust —-> 10 = Very Challenging to adjust)

Comfort

How would you rate the overall comfort of your new socket? (0 = Very uncomfortable —> 10 = Very comfortable)

0	1	2	3	4	5	6	7	8	9	10

(0 = Very uncomfortable —> 10 = Very comfortable)

How do you feel that any discomfort of your new socket will impact the activities you choose to do? (0 = Not at all limited, it’s comfortable —> 10 = Constantly limited by discomfort)

0	1	2	3	4	5	6	7	8	9	10

(0 = Not at all limited, it’s comfortable —> 10 = Constantly limited by discomfort)

Do you feel a difference in lower back pain so far with this new socket? (0 = Less lower back pain—> 5 —> No Difference —> 10 = More lower back pain)

0	1	2	3	4	5	6	7	8	9	10

(0 = Less lower back pain—> 5 —> No Difference —> 10 = More lower back pain)

Sitting Comfort

How would you describe your range of motion in your new socket? (0 = Extremely restricted—> 10 = Unlimited range of motion)

0	1	2	3	4	5	6	7	8	9	10

(0 = Extremely restricted—> 10 = Unlimited range of motion)

How would you rate the overall sitting comfort of your new socket? (0 = Very uncomfortable —> 10 = Very comfortable)

0	1	2	3	4	5	6	7	8	9	10

(0 = Very uncomfortable —> 10 = Very comfortable)

Heat and Sweat

How would you rate the temperature inside your new socket? (0 = It feels cool and comfortable —> 10 = It feels extremity hot)

0	1	2	3	4	5	6	7	8	9	10

(0 = It feels cool and comfortable —> 10 = It feels extremity hot)

How would you rate how much you sweat inside your current socket? (0 = No sweat at all —> 10 = Extreme amount of sweating)

0	1	2	3	4	5	6	7	8	9	10

(0 = No sweat at all —> 10 = Extreme amount of sweating)

Quality of Life and Hope

To what extend do you feel the Slingshot Socket™ will provide you with an improved quality of life? (0 = No improvement—> 10 = I expect a better quality of life through the Slingshot Socket™)

0	1	2	3	4	5	6	7	8	9	10

(0 = No improvement—> 10 = I expect a better quality of life through the Slingshot Socket™)

Do you have any activities or hobbies that you hope to be able to return to now with your Slingshot Socket™ that you were unable to participate in with your previous socket?

Yes

Please list them here

How likely is it that you would recommend the Slingshot Socket™ to a friend or fellow amputee? (0 = Very Unlikely—> 10 = Very Likely)

0	1	2	3	4	5	6	7	8	9	10

(0 = Very Unlikely—> 10 = Very Likely)

Fitting Experience

How were you fit with the Slingshot Socket?

I fit myself

Slingshot Bionics Clinic fit me

My local prosthetist fit me

How would you rate the proficiency of your practitioner in fitting the Slingshot Socket™? (0 = Not at all Proficient —> 10 = Very Proficient)

0	1	2	3	4	5	6	7	8	9	10

(0 = Not at all Proficient —> 10 = Very Proficient)

How would you rate the workmanship of your final delivered socket? (0 = Poor quality —> 10 = Excellent quality)

0	1	2	3	4	5	6	7	8	9	10

(0 = Poor quality —> 10 = Excellent quality)

What stood out the most about your experience being fit with the Slingshot Socket™?

Practitioner's Name

Clinic Name

Would you recommend your prosthetist to other amputees?

Yes

Consent*

We never share your information. By continuing you are protected under our privacy policy *

The Slingshot Socket™ is about restoring quality of life previously lost due to uncomfortable sockets.

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