Age:
Race or Ethnicity:
City or Town:
Occupation:
Type of Mobility Aid:
Hand propelled or electric:
Medical Condition requiring Mobility Aid:
What objects do you have trouble reaching:
Home:
Work:
Public places:
Your Height:
Your Weight:
If you use an electric mobility aid, how could the placement of the controls be improved?
if you use a wheelchair, how is it sized for you? (Too short, too tall, too wide, too narrow, etc.)
Have you ever had an injury attributable to your mobility aid? Please describe: