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Client Evaluation Form for AT Equipment

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1.  

Please tell us who is completing the evaluation form? 

* required
2.  

Do you (or the person you are responding on behalf of) live alone?

* required
3.  

Which item of Assistive Technology equipment did you use?

* required
4.  

What was the duration of the trial of the equipment?

* required

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6.  

Was the equipment easy to use?

7.  

Please indicate how helpful or unhelpful you found the equipment?

* required
8.  

Would you consider using the product long term?

* required
9.  

Has the level of care (if any) you receive changed as a result of using the equipment?

* required

Maximum 255 characters

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11.  

Has using the equipment helped reduce carer stress?

* required

Maximum 255 characters

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