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



My LiteGait Experience

• Please share a general or specific LiteGait story with us that depicts your experience using LiteGait.*

I would like information on

• *Becoming a LiteGait trainer: Yes No
• *Presenting a 15 minute Case Study as part of our webinar series: Yes No

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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:

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• 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 would need your contact info to provide support regarding your problem above!
• *Name:


• *Email:


• Best phone number to reach you:


• *Facility name:


• *City *State Not in US Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

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