Customer survey

Intake

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 year were you born?

What is your current weight (in pounds)?

What is your height?

Amputation

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 was the primary cause of the amputation?

Vascular Disease

Complications from Diabetes

Trauma

Infection

Congenital (I was born with it)

Other

When did you have this amputation (approximate if needed)?*

Current socket

How many months have you been wearing your current 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

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)

How much do you feel you use your residual limb muscles in your current socket? (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

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

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 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)

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)

Volume Management

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

0 Ply

1-2 Ply

3-5 Ply

5+ Ply

I do not wear socks

Unsure

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

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 = Unimportant —-> 10 = Very Important)

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 important is it to you to have more comfort in your socket? (0 = Unimportant—> 10 = Very important)

0	1	2	3	4	5	6	7	8	9	10

(0 = Unimportant—> 10 = Very important)

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 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)

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 important is it for you to have unrestricted range of motion and comfort while sitting? (0 = Unimportant —> 10 = Very important)

0	1	2	3	4	5	6	7	8	9	10

(0 = Unimportant —> 10 = Very important)

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)

How important is sweat reduction and socket breathability to you? (0 = Unimportant —> 10 = Very important)

0	1	2	3	4	5	6	7	8	9	10

(0 = Unimportant —> 10 = Very important)

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 “hope” for an improved quality of life? (0 = No added hope —> 10 = I have hope for a better quality of life through the Slingshot Socket™)

0	1	2	3	4	5	6	7	8	9	10

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

Do you have any hobbies or goals that you have not been able to do with your current prosthesis due to discomfort?

Yes

List them here for "Yes"

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

Slingshot Bionics

How did you hear about Slingshot Bionics or the Slingshot Socket™?

Facebook

Other social media ad

Print advertisement

Slingshot Bionic website

My prosthetist

Internet search (like Google)

Social media group

Another amputee or support group

Amputee Coalition of America

Other

Any additional comments?

Consent*

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

Customer survey

Intake

Amputation

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

Slingshot Bionics

Have Any Questions?

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