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Polio Australia survey on orthotics device use and satisfaction
This is an anonymous survey for Polio Survivors, divided into three sections. It should take no longer than 15 minutes to complete.

If you have any questions or concerns related to this questionnaire, please contact Paul Cavendish (Clinical Health Educator, Polio Australia) on 0466 719 013 or paul@polioaustralia.org.au.

Polio Australia thank you for your assistance in providing feedback on orthotic devices and your satisfaction levels with these to health professionals who work with orthotic prescription.

Polio Australia’s vision is that all polio survivors in Australia have access to appropriate health care and the support required to maintain independence and make informed lifestyle choices.

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Your answer
Gender
Polio Effects- Lower Body
Please indicate any weakness/paralysis in the body due to a history of Polio from the options below
Weakness in the lower body
Left leg
Right leg
Below the knee
At the knee
At the hip
The whole leg
Polio Effects- Upper body
Please indicate any weakness/paralysis in the body due to a history of Polio from the options below
Weakness in the upper body
Left arm
Right arm
Hand function
Elbow/forearm
Shoulder
The whole arm
Use of Assistive devices for ambulation
Use of assistive devices for ambulation
Never used it
Previously used it
Currently use it
Cane/s
Crutches
Walker
Scooter
Wheelchair
No use of an assistive device (after Polio virus)
Other type of assistive device (please describe):
Your answer
Use of orthotic devices
Use of orthotic devices
Never used it
Previously used it
Currently use it
Insoles / arch support
Customised shoe
Ankle foot orthosis (foot/ankle caliper)
Knee ankle foot orthosis (knee caliper)
Other type of orthotic device (please describe):
Your answer
On a typical day, please indicate the average number of hours (when you are awake), you spend wearing your orthotic:
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