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Exit Survey
 
 
The following survey sponsored by the Western University of Health Sciences will be used only for research purposes. Your participation is completely voluntary. It will focus on foot and ankle injuries among backpackers. You are being asked to participate as an identified backpacker. You may decline to participate without penalty. If you have any questions, contact:

Laura Poindexter at [email protected]
and/or
WesternU IRB at (909)469-5636
309 E. Second St., Pomona, CA 91766

---------------------------------------------------------
I have read, understood, and agree to the above consent form and desire of my own free will to participate in this study.

 
 
 
 
Age:
   
 
 
Gender:
 
Female
 
Male
 
 
Height:
   
 
 
Weight:
   
 
 
 
How would you describe your previous backpacking experience?
 
Extensive
 
Intermediate
 
Low
 
 
 
This section asks a few questions about your hiking style and habits.
 
 
 
What distance (in miles) have you hiked so far on this trip?
   
 
 
What is your average daily mileage?
   
 
 
What is your base pack weight (not counting food or water)?
   
 
 
 
What shoe type do you wear?
 
Sandal/minimal
 
Running shoe
 
Hiking shoe
 
Hiking boot
 
 
Did you hike in your shoes prior to this trip?
 
Yes
 
No
 
 
What best describes the socks you wear?
 
None
 
Single thin
 
Single thick
 
Double
 
 
How many sock pairs do you use for hiking?
   
 
 
 
This section asks about your foot and ankle health any time prior to starting your current trip.
 
 
Have you previously had:
Yes No
Blisters on your feet
Toenail injuries or illness
Stress fractures in your feet
 
 
 
Have you previously had other broken bones in your feet, legs, or hips?
 
Yes
 
No
 
 
If yes, describe:
   
 
 
Have you previously had:
Yes No
Ankle sprain
Other ankle pain
Knee pain
Hip pain
Back pain
 
 
 
Have you previously had foot or ankle surgery?
 
Yes
 
No
 
 
If yes, describe:
   
 
 
 
Have you previously had other musculoskeletal surgery below the waist?
 
Yes
 
No
 
 
If yes, describe:
   
 
 
Have you previously:
Yes No
Worn custom orthotic inserts
Worn over-the-counter shoe inserts
Had very sweaty feet
 
 
 
This section is about any complaints you have on this current trip.
 
 
 
Have you had foot blisters?
 
Yes
 
No
 
If yes, check all locations you have had blisters:
Right Left
Big toe
2nd toe
3rd toe
4th toe
5th toe
Ball of foot (inner)
Ball of foot (middle)
Ball of foot (outer)
Inner arch
Outer arch
Inner heel
Outer heel
Back of heel
Other
 
 
On this trip, have you had:
Yes No
Any toenail injury
Athlete's foot (foot fungus)
Ankle sprain
Stress fractures in your foot
 
 
 
On this trip, have you had any other broken bones (beside stress fractures)?
 
Yes
 
No
 
 
If yes, describe:
   
 
 
Rate your pain levels on this trip from 0 (no pain) to 10 (worst pain imaginable) for the following regions:
0 1 2 3 4 5 6 7 8 9 10
Heel
Ankle
Knee
Hip
Back
 
 
 
On this trip, have you had areas of tingling or numb skin?
 
Yes
 
No
 
 
If so, describe:
   
 
 
 
Almost done! This section asks about any treatments you've used during this trip.
 
 
 
Are you currently taking medication?
 
Yes
 
No
 
 
If yes, what medication(s)?
   
 
 
Are you currently using:
Yes No
Custom orthotic inserts
Over-the-counter shoe inserts
Moleskin or other padding products
Foot powder
 
 
 
Are you currently taping or bracing any joint?
 
Yes
 
No
 
 
If yes, which joint?
   
 
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