WHEELCHAIR USERS  
FEEDBACK FORM FOR WHEELCHAIR USERS
Email *
HOSPITAL/HEALTH CARE UNIVERSITY
DATE
*
MM
/
DD
/
YYYY
PATIENT NAME
*
Medical History *
PATIENT AGE
*
PATIENT SEX
 *
Able to move wheelchair by head movements *
Able to move wheelchair by Voice module  *
Able to move wheel chair by hand joystick *
Able to move wheel chair by leg joystick *
Able to move wheel chair by Braille *
Overall Satisfaction
 *
A copy of your responses will be emailed to .
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