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Clinicians' Questionnaire
Questions regarding patient's experience with the wheelchair fitting process as well as with the wheelchair itself.
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* Indicates required question
Email
*
Your email
Name
Your answer
Role/Title
Your answer
Professional Qualification (e.g PT / OT)
Physical Therapist (PT)
Occupational Therapist (OT)
Assistive Technology Professional (ATP)
None
Other:
Clear selection
Organization
Your answer
Contact info
Your answer
What fraction of your patients that use a wheelchair are under 18 years of age?
Your answer
What fraction of your patients that use a wheelchair are over 64 years of age?
Your answer
How long does the first wheelchair fitting appointment take for a first-time user?
Choose
< 1 hour
1-1.5 hours
>1.5 hours
How many wheelchair fitting appointments do first-time users have with you before their wheelchair is prescribed / ordered?
1
2
3
>3
Clear selection
What percent of first-time users return for a refitting once they have received their wheelchair?
Choose
0-25%
26-50%
51-75%
>75%
How long does a wheelchair fitting process take for a returning user?
Choose
< 1 hour
1-1.5 hours
>1.5 hours
How many wheelchair fitting appointments do returning users have with you before their wheelchair is prescribed / ordered?
1
2
3
>3
Clear selection
What percent of returning users get a refitting once they have received their wheelchair?
Choose
0-25%
26-50%
51-75%
>75%
Do wheelchair users come back to you because they have concerns about the fit of their wheelchair? If so (on average) how long after they received their wheelchair (in years) ?
Choose
<1
1-2
>2
How often (in years) do users get a new wheelchair (on average)?
Choose
1
2
3
4
5
>5
What's the main reason they change their wheelchair?
Choose
Upgrade (lighter, more versatile unit)
Change of lifestyle
Replacement
Bad fitting
How do you store individual wheelchair prescriptions?
Choose
Digitally (Hospital-only Data Warehouse)
Digitally (Central Data Warehouse)
Patient Case File (Paper)
How do you share individual wheelchair prescriptions?
E-mail
Post
Data-management system
Clear selection
For Medicare, what reimbursement-code is the fitting billed under?
Your answer
For Medicare clients, how many reimbursement-codes are used for the wheelchair billing?
Choose
1
2
3
>3
What percentage, in your experience, pay out of pocket for their wheelchair?
Choose
<10%
11-25%
26-50%
51-75%
>75%
What words would you use to describe those that are self-paid?
Your answer
Do any wheelchair users who do not work self pay for their wheelchairs?
Your answer
Would a modular wheelchair that can be adapted to different functions (e.g. they could buy and swap in different front wheels for off-road, sand, snow, sports, office etc.)
Yes
No
Maybe
Clear selection
Would a modular wheelchair that could be adapted to the user's style (e.g. they could buy and swap in different colour seats to match their clothing) be of interest to your clients?
Yes
No
Maybe
Clear selection
Can you think of other people / organisations that would be interested in / benefit from a modular wheelchair?
Your answer
If possible, please provide us a contact or lead that could put us in touch with wheelchair users.
Your answer
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