Upper Limb Loss Questionnaire

Your Level of Limb Loss?

Please specify your level of upper limb loss? *
Please tick as many boxes as apply

Your Service

Does your Limb Centre have a Doctor/Consultant? *

Yes
No
Don't Know

If yes, have you ever seen the Doctor/Consultant?

Yes
No
Don't Know
Not Applicable

Were goals/targets set for your rehabilitation? *

Yes
No
Don't Know

If yes, were these goals discussed & agreed with you?

Yes
No
Don't Know
Not Applicable

Is your General Practitioner involved in any way with your treatment? *

Yes
No
Don't Know

Assistive Technology & Helpful Equipment

Do you use any helpful equipment? *
such as front door openers, bathroom aids, etc.

Yes
No
Don't Know

Your Experience

How many years have you worn your present artificial limb(s)? *

How many hours a day do you usually wear your limb(s)? *

Do you ever experience phantom limb pain? *

How would you rate this pain on a scale of 1-10? *

How do you usually travel to and from your Centre? *

Are you happy with your travel arrangements? *

Yes
No
Don't Know

If no, please explain why

How True Are The Following Statements For You?

My limb(s) is/are comfortable throughout the day *

The weight of my limb(s) is/are manageable *

My limb(s) is/are easy to put on/take off *

My limb(s) look good *

My limb(s) do not need repairs/maintenance *

My limb(s) hurt me *

I would like dexterity / grip improved *

Please feel free to provide any additional information / details

Staff Attitudes

Please rate the attitude of your Limb Centre Doctor / Consultant *

Please rate the attitude of your Prosthetist *

Please rate the attitude of your Occupational Therapists & Physiotherapists *

Please rate the attitude of your Limb Centre Receptionists *

Please feel free to provide any additional information / details

If your limb is NOT comfortable, have you ever discussed this with your Prosthetist? *

Yes
No
Not Applicable

If your limb is NOT comfortable, have you ever discussed this with your Consultant / Limb Centre Doctor *

Yes
No
Not Applicable

Please feel free to provide any additional information / details

Were your complaints acted upon satisfactorily by your Prosthetist? *

Yes
No
Not Applicable

Were your complaints acted upon satisfactorily by your Consultant / Limb Centre Doctor? *

Yes
No
Not Applicable

Please feel free to provide any additional information / details

Your Limb(s)

Do you feel you have a choice of limb? *

Yes
No
Don't Know

Are you made aware of new designs as they become available? *

Yes
No
Don't Know

Are you offered new designs as they become available? *

Yes
No
Don't Know

Do you have a spare limb or limbs? *

Yes
No

Have you requested a spare limb and been denied? *

Yes
No

Your Appointments

From first meeting your Prosthetist, how long did you wait to get your satisfactory first, or new, limb? *

How often do you need to attend your Limb Fitting Centre for repairs/adjustments? *

Please feel free to provide any additional information / details

After requesting an appointment to see the Prosthetist, typically, how long do you wait to see him/her? *

How long usually do you wait in Reception? *

How long do you usually wait in the Fitting Room before you see your Prosthetist? *

Do you usually see the same Prosthetist? *

Yes
No

How many other amputees is your Prosthetist seeing at the same time as you? *

Do you feel that your Prosthetist has to see too many people during your attendance? *

Yes
No

Typically, when you request a repair to your limb, can this be done on the same day? *

Yes
No

If yes, how long do you typically wait?

Have you ever seen a Technician in the Fitting Room? *

Yes
No
Don't Know

User Groups

Does your Centre have a User Group? *

Yes
No
Don't Know

If yes, do you ever attend your Centre's User Group meetings?

Yes
No

If you don’t attend User Group meetings please would you provide the main reasons why?
Please write as much as you like or need. We want to get your full views.

General Service

What, if anything, in the service you receive would you most like to see changed or altered? *
Please write as much as you like or need. We want to get your full views.

Who or what has been the most helpful to you during your entire rehabilitation process? *
Please write as much as you like or need. We want to get your full views.

Your Personal Details

Please provide your personal details (voluntary). Your name and address will never be revealed to others and your responses will never be linked to your personal details. All information collected will be treated with the strictest of confidence.

First Name

Surname

Gender

Male
Female

Age

Email Address

Address

Postcode

Telephone Number

Date of Limb Loss (approx)

/ /

Which Limb Centre do you attend?

If other, please specify

Are you a Veteran?

Yes
No

Reason for Limb Loss?

* Denotes required field.

Upper Limb Loss Questionnaire

APLLG Questionnaire for people with Upper Limb Loss

Your Level of Limb Loss?

Your Service

Assistive Technology & Helpful Equipment

Your Experience

How True Are The Following Statements For You?

Staff Attitudes

Your Limb(s)

Your Appointments

User Groups

General Service

Your Personal Details