Amputee Reported Outcome Questionnaire Part A DEMONSTRATION ONLY If you are human, leave this field blank.Your Current LocationUKUSAEuropeAsiaPart A ClinicianGenderMaleFemaleAgeHeightWeightHow long have you been an amputee ?Months (if < 1 year)YearsWhat level is the amputation(s)?Left SidePartial footAnkle disarticulationBelow the kneeKnee disarticulationAbove the kneeHip disarticulationRight SidePartial footAnkle disarticulationBelow the kneeKnee disarticulationAbove the kneeHip disarticulationWhat was the cause of the amputation(s)?Vascular diseaseTraumaCancerInfectionCongenitalOtherIf other, please specifyOther health conditions (tick all that apply)DiabetesArthritisPeripheral vascular diseaseCancerHypertensionCardiovascular diseasePeripheral neuropathyBack painLower limb joint painPartial or full knee joint replacementHip joint replacementDescribe the knee and or ankle foot components used. Tick all that apply.KneeManual Lock/UnlockFriction devicePneumatic controlHydraulic controlMicroprocessor controlledIntegrated microprocessor knee & ankle systemOther control devicesAnkleSolid ankleArticulating ankleMulti-axial ankleEnergy storingHydraulic ankleMicroprocessor controlled ankle-foot systemDescribe the socket and suspension system and pylon components used. Tick all that apply.Socket / SuspensionOsseointegration implantI use stump socksI use a silicon or gel linerMy socket has a suction valveMy liner has a locking pinMy limb has a vacuum pumpMy limb is suspended using strap/belt suspensionPylonMy prosthesis has a rotation/torque deviceMy prothesis has a vertical shock pylonMy prosthesis has a combined shock/vacuum pumpMy prosthesis has a combined joint/vacuum pumpMy prosthesis has an electronic vacuum pumpHow is the prosthetic treatment funded ?State-funded (e.g. NHS in UK)InsuranceMilitary funding / VASelf-funded fullyInsurance and self-fundedInstructions for completion of Part BPlease provide the code below to your patient to enter when completing Part B. This allows the two halves to be associated during data analysis. Code: B093ASubmit Part AThank you for your time and feedback