Clinical Survey Form

Please take a few minutes to fill out our follow-up survey. For your time, we will send you a free gift and enter your name in our annual grand prize raffle. If you do not have any questions or do not want to participate in our prize drawings you can submit this form as a Guest.

We value your feedback and your information will not be sold or shared with any other organization.

• I am a Please Select PT PTA OT COTA SLP Supervisor Director Lead PT Staff Clinician Other  and I see Please Select Adults Peds Both patients.


• My facility is Please Select Inpatient Rehab Outpatient Rehab Skilled Nursing Facility Long Term Care Acute Hospital Adaptive PE Schools (K-12) Early Intervention Academic Prog.(PT/PTA/OT) Other


• Our facility has been using LiteGait®, WalkAble™ or Mobility Device for?
• Please Select 0-6 MO 6 MO - 1 Yr 1-2 Years 2-3 Years More than 3 Yrs


• The LiteGait is used with Select Treadmill Overground Both and Please Select Daily 2-3 Times a week Once a week Twice a month Less than once per month .


• Diagnoses we treat are:
  
Hold Ctrl key and click to select more than one
• Amputee CP Deconditioned MS Neuro Injury Ortho Parkinson Pediatrics Sports injury Other


• Results I have seen since using the LiteGait®, WalkAble™ or Mobility Device:

Please answer

• 1. Have you or any staff been to a course sponsored by the Education Department at Mobility Research? Yes   No  
• 2. Did your facility receive OnSite training with your LiteGait? Yes   No  
  


• 3. Have you utilized Clinical Support at Mobility Research for any clinical questions or problems (available at 1-800-332-WALK ext. 7153 or by email at PT@LiteGait.com)?
• Yes   No  
• If so, was this a valuable service for you? Please explain.

Did you know

• That you can send in, pictures and/or video of your use of LiteGait®, WalkAble™ or Mobility Device and the clinicians at Mobility Research can view it and provide feedback?
• Yes   No  
• That you may schedule an online refresher training? Yes   No  
• That you may order an OnSite training?      Yes   No  
• Have you visited us at www.LiteGait.com? Yes   No  
• Did you find all the information you needed on the site? Yes   No  
• Have you registered as a LiteGait user on our free clinical support forum? Yes   No  
• Have you become a fan of LiteGait yet? Yes   No  

Have a problem?


Click to let us know what we can assist you with.




I would like Clinical support regarding:

• Please Select Harness Application Protocol Information Pre-gait activities Overground walking Facilitation tips Onsite Training Crawling Alternative uses for PWB environment Mobility Device Competency check list Online refresher Training Treadmill use with LiteGait Other
• If Other, please specify:



I would like Technical support regarding:

• Please Select Battery BiSym Casters Treadmill Harness Other
• If Other, please specify:



I am interested in the following product information:

Hold Ctrl key and click to select more than one
• Additional Groin Pieces AutoStep BiSym Scale Crawling harness or attachments HugN-Go Flex Yoke FreeDome Yoke Gaiter Stool Gaitkeeper™ iharness + iGroin pieces Leg straps Mobility Device HugN-Go Short/Long torso harness ViTi Up
• If Other, please specify:

Please provide the following information:



• Wish to remain Anonymous. * In order to email your participation gift we need your valid contact info.
  We need your contact info to provide support.
• *Name:


• *Email:


• *Facility name:


• *Best phone number to reach you:

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