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Patient Satisfaction Survey


Your response to this evaluation form is extremely important to us. Its purpose is to help us monitor the quality of our patient care. Your answers to these questions will be kept strictly confidential. If you have any additional comments, please provide those at the bottom of the form.

  • Male     Female
  • Above Knee Prosthesis (AK)
  • AFO
  • Below Knee Prosthesis (BK)
  • Compression Stocking
  • Fracture Brace/Boot
  • Hip Brace
  • KAFO
  • Knee/Elbow Immobilizer
  • Neck Brace
  • Scoliosis Brace
  • Shoe Insert
  • Shoes
  • SMO
  • Soft Back Brace (corset)
  • Soft Wrist/Hand Brace
  • TLSO/LSO (Post-op back brace)
  • UCB
  • Upper Extremity Prosthesis
  •        Immediately
  •        Less than one week
  •        More than one week
  •        More than two weeks
  •        Yes
  •        No
  •        Yes
  •        No
  •        0-30 seconds
  •        30 seconds-1 min
  •        1-2 min
  •        more than 2 min
  •        Very well
  •        Somewhat well
  •        Not well
  •        Yes
  •        No
  •        Excellent
  •        Satisfactory
  •        Unsatisfactory
  •        Yes
  •        No
  •        Excellent
  •        Satisfactory
  •        Unsatisfactory
  •        Yes
  •        No
  •        Unsure
  •        Yes
  •        No
  •        Yes
  •        No
  •        Yes
  •        No
  •        Yes
  •        No
  •        Yes
  •        No
  •        Yes
  •        No
  •        Very valuable
  •        Somewhat valuable
  •        Not valuable

Commitment ~ Quality ~ Care