User Feedback Form

Date of report*

Organization that provided the new wheelchair or postural support device*

Client Name or I.D.*

Wheelchair Serial Number*

Completed by*

Name of the person that completed the report (if different from the wheelchair user)

PRODUCT INFORMATION

Note: Your wheelchair may look slightly different from the product image featured below.

1. Which type of product did you receive?*

2. Daily use environment (check all that apply)*

3. How often do you use your wheelchair or postural support device?*

3a. If you do not use your wheelchair or postural support device as often as you would like to, why? (check all that apply)

Answer this question only if you do not use the wheelchair as much as you would like to use it.

Please list your other reasons

3b. If you are experiencing problems with your product, you can attach pictures or video showing the problem

Drop files here or

Max. file size: 50 MB.

4. Please select any problems that you have had since receiving your product (check all that apply)*

Please list the other problems you have had

5. What health improvements you have had since you received your wheelchair or postural support device? (check all that apply)*

Please list the other health improvements you've had

6. From 1 to 5 (5 is very satisfied), how would you rate your overall satisfaction with the product you received?*

7. If you could change one thing about your new wheelchair or postural support device, what would it be?*

8. What impact has your wheelchair or postural support device had on your life? (check all that apply)*

Please list other ways your wheelchair or postural support device has impacted your life

9. Is there anything else you’d like to tell us about your new wheelchair or postural support device?*