Name *

First Name

Last Name

I'm a *

Caregiver

Tubie

Age of person with a feeding tube or infusion port *

<1

1-5 years

6-10 years

11-18 years

19-35 years

36-65 years

>65 years

How long have you or your loved one, had a feeding tube or infusion port? *

<1 year

1-5 years

6-10 years

>10 years

Check all that you currently use *

G, J or GJ-tube

NG-tube or NJ-tube

Infusion port

Other (please explain)

Check all that you currently use *

Pump feeds

Gravity syringe feeds

Gravity bag feeds

Push syringe feeds

Infusions

Other (please explain)

1. When using the FreeArm, I am confident in feeding or administering an infusion outside of the hospital or doctor’s office. *

Agree

Strongly agree

Disagree

Strongly disagree

2. Since having a FreeArm, I am confident in leaving home for a fun overnight or weeklong stay? (Example: vacation, overnight trip to visit family and friends, etc.) *

Agree

Strongly agree

Disagree

Strongly disagree

3. If pump feeding or administering infusions while using your FreeArm, what do you do now when you need to leave the house for a doctor appointment or other activity? *

Take FreeArm

Use a backback

Take an IV pole

Skip feeding

Leave the house during non-feed or non-infusion times

Other (please explain)

4. If pump feeding or administering infusions while using your FreeArm, where do you feed/infuse inside your home? *

Move FreeArm around the house to pump feed or administer infusions in different rooms.

Move IV pole around the house to pump feed or administer infusions in different rooms.

Pump feed or administer infusions in the same room every day using an IV pole or wall hook.

Use a backpack.

Other (please explain)

5. While using the FreeArm, how often do you leave your house and need to tube feed or administer an infusion while away from home? *

Often

Somewhat often

Somewhat never

Never

6. When using the FreeArm to hold a syringe for feeding, how often does vomiting or spitting up occur? *

Often

Somewhat often

Somewhat never

Never

N/A

7. If syringe feeding while using your FreeArm, what do you do now when you need to leave the house for a doctor appointment or other activity? *

Take FreeArm to hold syringe

Hold syringe in my hand

Skip feeding

Leave the house during non-feed time

Other (please explain)

N/A

8. If syringe feeding while using your FreeArm, how often are you able to perform therapies while holding the syringe? (For example: working on stretches or exercises, holding a pacifier in for a child with a feeding tube) *

Often

Somewhat often

Somewhat never

Never

N/A

9. If syringe feeding while using your FreeArm, how often are you able to do other activities while your FreeArm is holding the syringe? (For example: read or look at your phone for adults or read to your child with a feeding tube) *

Often

Somewhat often

Somewhat never

Never

N/A

10. If syringe feeding while using your FreeArm, how often do you spill a feed or medicine bolus? *

Often

Somewhat often

Somewhat never

Never

N/A

11. Since using the FreeArm, how often have you been readmitted to the hospital for feeding or infusion issues? *

1-3 times per month

4-7 times per month

8-10 times per month

>10 times per month

Never

13. Where is your favorite place to use your FreeArm? *

Bedside

In the car

On a side table

On a wheelchair or stroller

Sitting at a table

Other (please explain)