Amputee Reported Outcome Measure Part B DEMONSTRATION ONLY If you are human, leave this field blank.PART B (patient)Code from Part APlease enter the code provided by the clinician from Part A of this survey. (e.g. B012Z)How many times have you visited your prosthetic clinic in the last 12 months ?For more than 10, select 10.Are you in employment ?NoYes (part time)Yes (full time)RetiredStudentIs your mobility and health a factor in your employment status ?NoYesLiving statusLive aloneLive with family assistanceLive with visiting daily professional care assistanceLong term are facilityHow would best describe your walking environment (tick all that applies)Mostly level surfacesMostly level surface with occasional step / kerbMostly level surfaces with occasional steps and chairsMostly uneven surfaces with steps and chairsAmbulation type per weekPlease give a percentageWithin the home %Outside the home %Ambulation type per dayPlease give a percentageSeated %Standing %Walking %Running %Current assistive devices usedNoneCane / walking stickCrutchesWalker frameWheel chairAmbulation per dayIn meters (select 100 for <100 and 1000 for >1000)How would you describe your health today ?100 = best health you can imagine. 0 = worst health you can imagine.Which statement best describes your ambulation environment and mobility needs ?Mostly indoors, using walking aidsOccasional walking outdoors on mostly flat ground with or without the use of walking aidsWalking outdoors on various terrain and at different walking speeds without the use of walking aidsRigorous everyday activities such as construction work or regular sporting activityHow would you rate your overall walking mobility?1 = no problem 5 = I am unableHow would you rate your ability to wash and dress yourself ?1 = no problem 5 = I am unableHow often do you do the following activities ? Never Rarely Several times a month Several times a week DailyWalk up/down stairs Walk up/down ramps Carry or lift items Drive Sports activitiesHow would you rate the difficulties or usual daily activities like, working, leisure, housework etc ?1 = no problem 5 = I am unableHave you experienced any problems with your residual limb in the last 12 months?Select number of times you have experienced problems, select 10 if > 10.Have you fallen in the last 12 months and if so, how many times?Select 10 if > 10.What were you doing /main cause if you fell ?Tick all those that applyStandingWalking at normal paceWalking quicklyRunningLoss of balanceFatiguePoor visionI was in painIncline walkingUneven surfaceSlippery surfaceStep or kerbTrip obstacleStairsSitting - standing transferCarrying objectReaching for an objectPicking up an objectStepping backwardsStepping sidewaysHave you injured yourself falling ?No treatmentGPHospitalPhysiotherapistSelf-treatedIf so, did you seek professional medical treatment?How many days mobility have you lost per year from an injury caused by falling ?Number of times, select 10 if > 10.How many days mobility have you lost per year due to an injury / pain or discomfort caused by your prosthesis ?Number of times, select 10 if > 10.Have you ever intentionally limited your mobility to prevent an injury or to prevent an injury worsening ?Number of times, select 10 if > 10.In the last 12 months have you ever experienced a tissue breakdown, blister, ulcer or other injury of your amputated limb ?Number of times, select 10 if > 10.How often do you experience the following types of pain ? Never Every few months Once a month Once a week 2 - 3 times/week Every dayBack pain Phantom limb pain Socket pain Joint pain (amputated limb) Joint pain (intact limb)How would you rate the severity of the pain ?Rate out of 10, where 0 is no pain and 10 is the most intense pain possible ?Back painPhantom limb painSocket painJoint pain (amputated limb)Joint pain (intact limb)How would you rate the following ? Poor Fair Good Very Good ExcellentEase of standing from a chair Ease of sitting down from a chair Overall balance Ability to walk on inclines Confidence using my prosthesis outside My ability to walk on stairs Feeling of safety using my limb Comfort of my prosthesis My ability to walk at changing speeds My ability to walk on uneven surfaces My ability to stand for extended periods of timeHow does using your prosthesis make you feel ? Never Slightly Moderately Severely ExtremelyDepressed Anxious Worried afraid of outdoors and or busy environments Fear of fallingSubmit Part BThank you for your time and feedbackText