Biomechatronics Above-knee Prosthesis Study Interest Form
Your responses in this form will be used to determine candidacy for an ongoing clinical trial we are conducting regarding the myoelectric control of a powered knee prosthesis. Please direct any questions to Tony Shu (tonyshu[at]media.mit.edu).

Online recruitment materials can be viewed at: https://cctr.mit.edu/advanced-prosthesis-study
Sign in to Google to save your progress. Learn more
Name *
Email *
Age *
Above-knee amputation side. NOTE: we can only enroll you in this study if you have a unilateral lower-extremity amputation.  *
What is the length of your prosthesis from the ground to the middle of the knee joint with the shoe on? *
Height *
Body weight *
Amputation level *
Cause of amputation
Clear selection
Years since amputation *
Did you receive targeted muscle reinnervation (TMR) or targeted sensory reinnervation (TSR) in any form as part of your amputation procedure? *
Please provide details regarding the nature of your TMR/TSR (including innervation sites, nerves used, etc.) if possible.
Can you commute to the MIT Media Lab for 3 to 5 full-day testing sessions? *
We are located at 75 Amherst St., Cambridge, MA 02142. These days do not have to be sequential, but the time elapsed between the first and last session should be no longer than a month. Our hours are very flexible.
Can you walk comfortably with your prescribed prosthesis for at least 100 feet? Can you ascend and descend stairs with your prosthesis? *
These testing sessions may be physically demanding for some.
How did you hear about this study? *
Do you have anything else you would like to share?
Submit
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