User Feedback Form Date* MM slash DD slash YYYY Organization that provided the assistive product*Client Name or ID Number*Product Serial Number*Completed By* Client Caregiver/Parent Other Name of person completing this report (if different from client)PRODUCT INFORMATIONNote: Product may look slightly different from the image below. 1. What product did you receive?* DDO D-Lite Ultralight Rigid DDO D-Play Sports DDO D-Seat DDO D-Xbasic Active Foldable DDO D-XLite Ultralight Folding INTCO Active INTCO All-Terrain INTCO Transport Liberty II Motivation Active Folding Motivation Active Rigid Motivation Moti-Go Motivation Moti-Start Motivation Rough Terrain Motivation Rough Terrain with Clip-On Tricycle RoughRider 2. Daily use environment (check all that apply)* Indoor only Outdoor only Both indoor and outdoor Up and down hills In and out of a car In and out of a bus Transport on motorcycle Use on dirt surfaces often Often passes through water Use on uneven surfaces often 3. How often do you use your assistive product?* Rarely Once a week More than once a week Daily for less than 4 hours Daily for more than 4 hours 4. If you DO NOT use your assistive product as often as you would like to, why? (check all that apply) Wheelchair does not fit through doors Wheelchair is difficult to move Wheelchair is not working well Fear of falling out of chair Walking is easier for me Wheelchair is not needed often Using the wheelchair causes pain My environment is inaccessible Other 5. Please select any problems that you have had since receiving your product (check all that apply)* Pressure sores/ulcers Posture changes Shoulder pain Other None Please list any other problems you've had with your product6. If you are experiencing problems with your product, attach pictures or video showing the problem Drop files here or Select files Max. file size: 50 MB. 7. What health improvements have you experienced since you received your assistive product? (check all that apply)* Reduced pain Improved breathing Improved posture Other None Please list any other health improvements you've had8. From 1 to 5 (5 is very satisfied), how would you rate your overall satisfaction with the product you received?* 1 (Not Satisfied) 2 3 (Satisfied) 4 5 (Very Satisfied) 9. If you could change one thing about your new assistive product, what would it be?10. What impact has your assistive product had on your life? (check all that apply)* I can go to school I can go to work I was able to get a job I can go out with family and friends My life has not changed Other Please list any other ways your assistive product has impacted your life11. Is there anything else you’d like to tell us about your new assistive product?
