Customer survey

Follow Up

This information helps us measure the impact the Slingshot Socket™ has on quality of life, and compare it to your experience in your prior socket. 3-5 Minutes to complete

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Order Number # (if available)

Name*

First Last

Email*

Phone*

Practitioner’s Name

Clinic Name

What is your current weight (in pounds)?

Have you had any body weight changes since being fit with the Slingshot Socket™?

I have lost weight

No weight change

I have gained weight

Have you had any major health issues since being fit with the Slingshot Socket™ that impacts your ability to walk or use your prosthesis?

Yes

Please explain

Current socket

How many months have you been wearing your Slingshot Socket™?

Select all issues you are having with your current socket.

Pain or Discomfort

Restricted Range of Motion

Uncomfortable while sitting

Pistoning or Lack of Suspension

Skin breakdown/blisters/sores

Instability

Excess heat and sweat

Chronic back pain

Difficulty managing fit

Socket odors

Distal end discomfort

No problems

How would you rate the weight of your current 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

Have you experienced fewer skin issues or breakdowns in your Slingshot Socket™ than you did in your prior socket?

Yes

How often do you currently experience phantom limb pain? (0 = Never —> 10 = Frequently)

0	1	2	3	4	5	6	7	8	9	10

(0 = Never —> 10 = Frequently)

How severe is your phantom limb pain? (0 = Negligible —> 10 = Debilitating)

0	1	2	3	4	5	6	7	8	9	10

(0 = Negligible —> 10 = Debilitating)

In your current 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)

How would you describe the strength of your residual limb muscles? (0 = Weak —> 10 = Strong)

0	1	2	3	4	5	6	7	8	9	10

(0 = Weak —> 10 = Strong)

How would you describe the general health of your residual limb skin? (0 = Unhealthy and weak —> 10 = Healthy and strong)

0	1	2	3	4	5	6	7	8	9	10

(0 = Unhealthy and weak —> 10 = Healthy and strong)

Activity Level

Are you generally more active in your Slingshot Socket™ than you were in your prior socket?

Yes

How many hours do you wear your 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 is limited by my socket —> 10 = Unlimited with my socket)

What functional level are you? (If you do not currently use a prosthesis, choose what you think you could do potentially)

I can use my prosthesis to transfer or stand, but I cannot walk.

I can walk on level surfaces at a fixed speed.

I can walk and traverse some environmental barriers like curbs, ramps, and stairs.

I can easily walk at various speeds and manage most environmental barriers.

I can exceed basic walking and can participate in high impact activities such as running, sports, or exercise.

Stability and Ambulation Confidence

Do you feel more secure and less likely to stumble in your Slingshot Socket™ than you did in your prior socket?

Yes

Are you less dependent on assistive devices like crutches, canes, or walkers with your Slingshot Socket™ than you were in your prior socket?

Yes

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 much does your limb volume fluctuate each day in your current socket?

(If you don’t wear socks, guesstimate a sock-ply equivalent)?

0 Ply

1-2 Ply

3-5 Ply

5+ Ply

I do not wear socks

Unsure

Do you feel your limb volume now fluctuates less, the same, or more than it did in your prior socket?

Less volume change

Equivalent volume change

More volume change

About how many minutes each day in total do you spend adjusting the fit of your socket?

Less than 5 minutes

5-15 minutes

15-30 minutes

30-60 minutes

60-90 minutes

90+ minutes

To what extend do you have difficultly managing an appropriate fit throughout the day with your current socket? (0 = It is simple to manage the fit —-> 10 = It is challenging to manage the fit)

0	1	2	3	4	5	6	7	8	9	10

(0 = It is simple to manage the fit —-> 10 = It is challenging to manage the fit)

Comfort

How would you rate the overall comfort of your current 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 often does any discomfort or pain from your current socket 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)

How often do you experience lower back pain? (0 = Rarely ever —> 10 = Frequently)

0	1	2	3	4	5	6	7	8	9	10

(0 = Rarely ever —> 10 = Frequently)

Sitting Comfort

How would you describe your range of motion in your current 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 current 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 often does socket discomfort or impingement during sitting limit what sitting activities you choose to do? The limitations can include choosing to take your prosthesis off or choosing where or how to sit due to discomfort. (Impingement can be into the back of your knee (BK) or into the hips or abdomen (AK)). (0 = Never limited by socket impingement —> 10 = Constantly limited by socket impingement)

0	1	2	3	4	5	6	7	8	9	10

(0 = Never limited by socket impingement —> 10 = Constantly limited by socket impingement)

Heat and Sweat

How would you rate the temperature inside your current 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)

How often does the heat and sweat in your current socket limit the activities you choose to do? (0 = No limitations due to heat and sweat —> 10 = Constantly limited due to heat ands sweat)

0	1	2	3	4	5	6	7	8	9	10

(0 = No limitations due to heat and sweat —> 10 = Constantly limited due to heat ands sweat)

Quality of Life and Hope

How often is your quality of life limited by any kind of discomfort in your current prosthesis? (Discomfort can include any combination of pain, limited range of motion, heat, sweat, sitting discomfort, instability, or other factors) (0 = Not at all limited —> 10 = Constantly limited)

0	1	2	3	4	5	6	7	8	9	10

(0 = Not at all limited —> 10 = Constantly limited)

To what extend has the Slingshot Socket™ given you an improved quality of life, compared to your prior socket? (0 = No improvement—> 10 = I have a better quality of life through the Slingshot Socket™)Socket™)

0	1	2	3	4	5	6	7	8	9	10

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

Have you been able to return to any activities or hobbies with your Slingshot Socket™ that you were unable to participate in with your previous socket?

Yes

List them here for "Yes"

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)

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

Any additional comments?

Consent*

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

Customer survey

Follow Up

Current socket

Phantom Pain and Limb Health

Activity Level

Stability and Ambulation Confidence

Volume Management

Comfort

Sitting Comfort

Heat and Sweat

Quality of Life and Hope

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