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Patient Assessment Questionnaire

Through a series of questions we can determine the type of care needed.

Please fill out this form and we will get back to you as quickly as possible.

Patient Assessment

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Email

Questionnaire

When you imagine your finished prosthetic, which statement best describes your expectation?"

It should be completely undetectable - no one should ever know

It should look natural in normal social situations

It should provide good coverage and basic function

How involved do you want to be in creating your prosthetic?"

I want to provide input on every detail and refinement

I'd like to give feedback on major elements

I trust the professional to handle most decisions

If achieving the best possible result required additional appointments, how would you feel?

I'd welcome extra sessions to get it perfect

A few extra appointments would be fine

I prefer to minimize appointments and travel

Which statement best reflects your approach to this investment?

I want the highest quality possible regardless of cost

I'm willing to invest appropriately for good results

I need to work within insurance limitations

How do you feel about daily prosthetic care routines?"

I'm committed to whatever maintenance preserves the best appearance

I can handle reasonable daily care requirements

I prefer the simplest possible maintenance routine

Which activities are most important for you to resume confidently?

Professional presentations, close social interactions, photography

Normal daily activities, casual social situations

Basic public activities, family interactions

If you've had disappointing medical experiences before, what would help you feel confident this time?

Extensive consultation, seeing examples, being involved in every decision

Clear communication and realistic timelines

Straightforward process with minimal complexity

Regarding travel to our clinic

I can travel multiple times for optimal results

I prefer efficient scheduling but can make necessary trips

I need to minimize travel as much as possible

LOCATION

The Huyler Building
374 Delaware Ave, Suite 210 | Buffalo, New York 14202
phone 1 (855) 699-3222 or (716) 322-0003
fax (833) 918-8222

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HOURS:

Monday

1:00 pm-7:00pm

Tuesday

9:00 am-3:00pm

Wednesday

1:00 pm-7:00pm

Thursday

9:00 am-3:00pm

Friday

9:00 am-12:00pm