First Name: Last Name: Date of evaluation: New RX PresentNo RX Present Are you ambulatory: YesNo Is this the FIRST device of this kind you have received? YesNo If No, please answer the following questions. If Yes, please submit form Is the device you are currently wearing the last device you have received? YesNo On what date did you receive your most recent device? What company provided your most recent device? Company Name: Street address: City: State: Zip: Why is your current device not acceptable to you at this time? Is your current device Too bigToo smallJust worn out Have you gained weight since you received your last device? YesNo If yes, how much weight have you gained? Have you lost weight since you received your last device? YesNo If yes, how much weight have you lost? Has your condition worsened/changed since you received your last device? YesNo If yes, please explain On what date did your physician last examine you FOR THE DEVICE YOU ARE WEARING? Please enter an answer in digits: 11 − 4 =
