Special Mobility Survey
1.

At what age did your child require special mobility?

0-7 years old
8-12 years old
13-18 years old
>19 years old
2.

How old is your child currently?

0-7 years old
8-12 years old
13-18 years old
>19 years old
3.

Which type of adaptive chair(s) does your child currently use?

Stroller Type Push Wheelchair EX: Convaid, Kimba, Snugseat
Traditional Wheelchair (self propel,electric) EX: Quickie Iris, TiLite (Skip to Question 6)
Both
4.

At what age do you anticipate your child will no longer use a stroller type wheelchair?

0-7 years old
8-12 years old
13-18 years old
>19 years old
Never. I will always use a stroller type chair
5.
Why do you say that? Is it because...     (Select all that apply)
It is not age appropriate
The child will only use traditional, self propelled or electric chair
Finances
Others (please specify)
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6.
What sources do you use to stay current with your child's mobility needs?  (Select all that apply)
Personal Physician
Dealer
Therapist
Internet
Social Network
Magazine/Print Media
Manufacturers website
Support Groups
None
Other  
7.
How do you pay for your child's wheelchair and other special needs equipment? (check all that apply)
Cash (Skip to Question 13)
Credit Card (Skip to Question 13)
Insurance
Medicare/Medicaid
Charitable support/donations (Skip to Question 13)
Other  
8.

If you wanted a stroller type chair that you really loved for your child, but it was not covered by Insurance/Medicare/Medicaid, would you buy it on your own or get a push chair that the Insurance/Medicare/Medicaid provides?

Yes. I would buy the chair on my own. (Skip to question 15)
No. I would take the chair provided.
9.
If financing were available, what would you do?
Definitely buy the chair Probably buy the chair Might or might not buy the chair Probably would take the chair provided Definitely take the chair provided       
      
10.
What are your top issues that adaptive chair companies should address to make adaptive chairs more user friendly for either the user or the caregiver?
 

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