• What's your name?*
• Source
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• What's your email?*
  example@example.com
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• What is your phone number?*
  Please enter a valid phone number.Format: 0000 000 000.
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• What is your age?*
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• Do you currently use a mobility scooter?*
  a) Yesb) No
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• How often do you use your current mobility scooter?*
  a) Every dayb) More than 3 times a weekc) Once or twice a week or less
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• What is your height (in cm)?*
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• What is your weight (in kg)?*
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• What is your primary reason for needing a mobility scooter?*
  a) To go shoppingb) To visit friends within a 5 kilometer areac) To go outdoors mored) Something else
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• How far do you typically travel on your mobility scooter?*
  a) Less than 5KMb) Between 5-10 KMc) More than 10 KM
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• Do you primarily use your mobility scooter indoors or outdoors?*
  a) Indoorsb) Outdoors
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• What type of terrain do you typically encounter while using your mobility scooter?*
  a) Mainly indoors and on pavementsb) Rough groundc) A mixture of all the above
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• How important is speed to you when selecting a mobility scooter?*
  a) Very importantb) Somewhat importantc) Not important
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• How important is range (i.e. how far you can travel on a single charge) to you when selecting a mobility scooter?*
  a) Very importantb) Somewhat importantc) Not important
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• Do you need a scooter that can fold up for easy transport?*
  a) Yesb) No
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• How important is comfort (i.e. seat padding, back support, etc.) to you when selecting a mobility scooter?*
  a) Very importantb) Somewhat importantc) Not important
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• How important is manoeuvrability (i.e. how easy it is to turn and navigate through tight spaces) to you when selecting a mobility scooter?*
  a) Very importantb) Somewhat importantc) Not important
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• Have you ever customized a mobility scooter before?*
  a) Yesb) No
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• Are you NDIS funded?*
  YesNo
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• What is your budget for a mobility scooter?*
  a) $2,000 - $5,000b) $5,000 - $7,500c) $7,500 - $10,000d) More than $10,000
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• How would you like us to contact you?*
  Phone callEmail
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• Wonderful. Based on your answers, we have a solution for you. As we know this is a big decision, we have a mobility specialist ready to answer any further questions you have and walk you through our recommendation. What is the best time of day to contact you?*
  MorningAfternoonEvening
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• Thank you for completing the assessment.
  Please click the Submit button to complete the survey.

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