User feedback

The purpose of this survey is to collect information that can guide the development of a new type of ostomy product. We at Ampa want to understand how people with ostomies use and manage their ostomy products in their daily lives, and what challenges they face. At the same time, we want to hear your opinion about a new product we have developed.

We ask that you answer the questions as accurately as possible. Your participation in this survey is important to us, and we appreciate your time and effort. Thank you for agreeing to participate in the survey.

The expected time to complete the questionnaire is about 20 minutes.

The survey is completely anonymous.


Part 1

General information about you, your usage patterns, and what affects you most in relation to your ostomy.

Sign in to Google to save your progress. Learn more
What is your current country of residence?
 *

How old are you? (years)

 *
What is your sex? *

What is your approximate weight? (kg)

 *

What is your approximate height? (cm)

 *

Is your ostomy

 *
How long have you had your ostomy?
 *
Please indicate your experience with hernia
 *

What is the reason for your ostomy? (multiple answers possible)

 *
Required

If you are aware, how much of your intestine is left? (in meters)

What is the typical consistency of your ostomy output? (Multiple choices possible if it varies)
 *

What is your estimated daily (24-hour) output?

A standard drinking glass can typically hold about 200-250 ml of water.

 *

How often do you empty your bag in a day?

 *
Which system do you use?
 *

How many bags do you use per week? (number)

 *
How much money do you spend on ostomy products including accessories annually (reimbursed)?
 *
How many times have you been seen at the ostomy clinic in the last year? (number)
 *
If relevant, please specify the reason for your visit to the stoma clinic
How many sick days have you had due to your ostomy in the last year? (number)
 *
If relevant, please specify the reason for your days
Do you experience air release from your ostomy?
 *
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms