Survey

Elevate Brace Questionnaire
1= very difficult/uncomfortable, 2 =difficult, 3 = neither difficult nor easy, 4 = easy, 5 = very easy/ comfortable

* Indicates required field

Physician Name *

First

Last

Physician Email *

1. Overall, was the brace easy to put on and take off? *

1 2 3 4 5

2. Was the magnetic fastener easy to use? *

1 2 3 4 5

a. What, if any issues did you have with the magnetic fastener? *

3. Did you need to adjust the brace after the initial adjustment? *

Yes No

4. If adjustments were made, how easy/difficult was it to make them? *

1 2 3 4 5

5. Was it difficult putting the brace on and off after the first time? *

1 2 3 4 5

6. Was the wrist component easy to use? *

1 2 3 4 5

7. Was the wrist component comfortable? *

1 2 3 4 5

8. Were there any problems with the wrist component? *

9. Was the torso component easy to use? *

1 2 3 4 5

10. Was the torso component comfortable? *

1 2 3 4 5

11. Were there any problems with the torso component? *

12. How comfortable was the complete brace to wear for long periods of time? *

1 2 3 4 5

14. How much do you think is fair to pay for for this brace off the shelf at a pharmacy or drugstore? *

15. Please give us any recommendations or suggestions: *

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