Results 1 to 6 of 6

Thread: everyone please fill out the survey!

  1. #1
    Member weed hopper's Avatar
    Join Date
    May 2003
    Location
    west texas usa
    Posts
    98

    everyone please fill out the survey!

    i am posting this survey for a quadriplegic college student in colombia...please complete the survey and email it to annieromero16@cable.net.co


    USERS OPINION
    GENERAL INFORMATION

    AGE _____________________________
    STATE _____________________________
    GENDER _____________________________

    PERSONAL INFORMATION
    MARITAL STATUS: SINGLE ____
    MARRIED ____
    DIVORCED/ SEPARATED ____
    WIDOWED ____

    ARE YOU CURRENTLY WORKING?:
    YES ____ NO ____
    RETIRED ____ FREE LANCE ____
    HOMEMAKER ____ STUDENT ____

    DO YOU LIVE IN: HOUSE ____
    APARTMENT ____
    RENT ____ OWN ____

    INTERESTS: READING ____
    WRITING ____
    LISTENING TO MUSIC ____
    COMPUTERS/INTERNET ____
    SPORTS ____
    HIGHEST EDUCATION
    HIGH SCHOOL ____
    SOME COLLEGE (<2 YRS) ____
    UNIVERSITY (>2 YRS) ____
    SPECIALIZATION ____
    OTHER ____

    PHYSICAL CONDITION
    PRESENT DAY: PARAPLEGIC ____
    TETRAPLEGIC ____
    HEMIPLEGIC ____
    AMPUTEE, WHICH PART __________

    BECAUSE OF YOUR PHYSICAL CONDITION, WHAT DO YOU USE TO MOVE AROUND OR GO SOMEWHERE: WHEELCHAIR ____
    CANES ____
    WALKERS ____
    CRUTCHES ____

    WHERE DO YOU BUY YOUR MEDICAL (HOSPITAL) AND ORTHOPEDICS EQUIPMENT:
    __________________________________________________ __

    IF YOU USE A WHEELCHAIR, PLEASE ANSWER THE FOLLOWING:
    WHAT KIND IS IT: MANUAL ____
    ELECTRIC ____
    3-4 WHEEL SCOOTERS ____

    WHAT BRAND IS IT: QUICKIE ____
    ACTION ____
    EVEREST ____
    OTHER ____ _____________________

    HOW LONG DO YOU STAY ON IT PER DAY:
    BETWEEN 2 & 4 HOURS ____
    BETWEEN 4 & 8 HOURS ____
    BETWEEN 8 & 12 HOURS ____
    BETWEEN 12 & 14 HOURS ____
    MORE ____

    ADVANTAGES OF IT:
    1. _____________________________________
    2. _____________________________________
    3. _____________________________________

    DISADVANTAGES OF IT:
    1. ______________________________________
    2. ______________________________________
    3. ______________________________________

    HOW MUCH DID YOU PAY FOR IT:
    BETWEEN US$ 0 & US$ 500 ____
    BETWEEN US$ 500 & US$ 1000 ____
    BETWEEN US$ 1000 & US$ 1500 ____
    BETWEEN US$ 1500 & US$ 2000 ____
    BETWEEN US$ 2000 & US$ 2500 ____
    BETWEEN US$ 2500 & US$ 3000 ____
    MORE ____

    WHAT SUGGESTIONS YOU CAN MAKE FOR IT:
    1. ______________________________________
    2. ______________________________________
    3. ______________________________________

    WHAT ACTIVITIES DO YOU PERFORM ON IT:
    ONLY TO MOVE AROUND OR GO SOMEWHERE ____
    PRACTICE ANY SPORT ____
    OTHER ____

    DO YOU HAVE A DIFFERENT WHEELCHAIR?:
    YES ____ NO ____
    IF YES:
    BATH ____
    TRAVEL ____
    BEACH ____
    REST ____
    OTHER ____

    HOW MUCH DID YOU PAY FOR IT:
    BETWEEN US$ 0 & US$ 500 ____
    BETWEEN US$ 500 & US$ 1000 ____
    BETWEEN US$ 1000 & US$ 1500 ____
    BETWEEN US$ 1500 & US$ 2000 ____
    BETWEEN US$ 2000 & US$ 2500 ____
    BETWEEN US$ 2500 & US$ 3000 ____
    MORE ____

    WHAT CHARACTERISTICS WOULD THE PERFECT WHEELCHAIR HAVE FOR YOU?:
    1. ______________________________________
    2. ______________________________________
    3. ______________________________________

    HOW MUCH WOULD YOU INVEST IN THIS WHEELCHAIR?:
    BETWEEN US$ 0 & US$ 500 ____
    BETWEEN US$ 500 & US$ 1000 ____
    BETWEEN US$ 1000 & US$ 1500 ____
    BETWEEN US$ 1500 & US$ 2000 ____
    BETWEEN US$ 2000 & US$ 2500 ____
    BETWEEN US$ 2500 & US$ 3000 ____
    MORE ____
    WHAT IS YOUR COMBINED ANNUAL INCOME OF ALL FAMILY MEMBERS IN YOUR HOUSEHOLD?

    A. LESS THAN $10,000
    B. LESS THAN $15,000
    C. LESS THAN $20,000
    D. LESS THAN $25,000
    E. LESS THAN $35,000
    F. LESS THAN $50,000
    G. LESS THAN $75,000
    H. $75,000 OR MORE

    WILL YOU BUY A SECOND HAND ITEM?:
    YES ____ NO ____

    WILL YOU BE WILLING TO BUY A MULTI FUNTIONAL WHEELCHAIR WHICH FUNCTIONS AS:
    CONVENTIONAL WHEELCHAIR,
    BATH AND BATHROOM WHEELCHAIR,
    DINNER, READ AND WRITE TABLE, WITH CUPHOLDERS,
    WITH THE ABILITY TO MOVE BY YOURSELF WHEN YOU ARE USING IT, AND THE POSIBILITY TO DISARM AND PACK IT IN A HANDBAG TO TAKE IT IN A TRIP.
    YES ____ NO ____

    HOW MUCH WOULD YOU EXPECT THE COST OF THE LAST WHEELCHAIR TO BE WITH THOSE CHARACTERISTICS?:
    BETWEEN US$ 0 & US$ 500 ____
    BETWEEN US$ 500 & US$ 1000 ____
    BETWEEN US$ 1000 & US$ 1500 ____
    BETWEEN US$ 1500 & US$ 2000 ____
    BETWEEN US$ 2000 & US$ 2500 ____
    BETWEEN US$ 2500 & US$ 3000 ____
    MORE ____

    "you never know what tomorrow may hold "

  2. #2
    Someone please remove this shit.

  3. #3
    Member weed hopper's Avatar
    Join Date
    May 2003
    Location
    west texas usa
    Posts
    98
    can't we all just gimp along!

    "you never know what tomorrow may hold "

  4. #4
    Oh yeah, I would love to get one of those bathroom & standard wheelchairs with a table and cupholder (and hopefully some fine china on it) that I would be ever so grateful to move myself & pack it away in my handbag for trips using my $0-500 regular wheelchair! Who dreams up this shit?

    Andy

  5. #5
    I don't have time to fill this out... I am busy picking my nose

    -Lewis

  6. #6
    Senior Member
    Join Date
    Oct 2001
    Location
    oklahoma
    Posts
    2,335
    i want some of them stirrups like the gyno has mounted 1 above each shoulder. would provide great comfort for me & lady passengers

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •