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  • Lower Extremity Prosthesis Prescription

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    Patrick Muljono
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    6 views1 page

    Lower Extremity Prosthesis Prescription

    Uploaded by

    Patrick Muljono

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    LOWER-LIMB PROSTHETIC PRESCRIPTION

    Name: ______________________________________________________________ Date: __________________

    Age: _____ Sex: ______ Height:: _________ Weight: __________ Occupation: ______________________

    Amputation level and side (R = Right, L = Left, B = Bilateral): ________________________________

    Construction: Exoskeletal _____________________ Endoskeletal ________________________________

    Hip Disarticulation Socket _____________________________


    Hemipelvectomy Socket _______________________________

    Transfemoral Transtibial

    SOCKET SOCKET
    Quadrilateral total contact ____________ Conventional _______________________
    Ischial containment total contact PTB _______________________________________
    Knee disarticulation __________________ Interface (specify material)
    Soft Insert___________________
    SOCKET MATERIAL and/or construction Hard w/Soft End ______________________
    Flexible ______________________________ Other ______________________________
    Rigid _________________________________
    Other, Specify ________________________

    SUSPENSION SUSPENSION
    Suction ______________________________ PTB Proximal Walls__________________
    Silesian belt _________________________ Supracondylar, Suprapatellar _______ Silicone
    suction/hypobaric ___________ Supracondylar ______________________
    Pelvic band with hip joint_____________ Removable Wall or Wedge ___________
    TES belt _____________________________
    Other, specify ________________________ Cuff ________________________________

    KNEE JOINT Sleeve _______________________________


    Single axis constant friction___________ Silicone suction ____________________
    Single axis constant friction with Joints and corset ___________________
    stance control _____________________ Ischial weight bearing _______________
    Polycentric ___________________________ Other ______________________________
    Fluid control _________________________
    Pneumatic ____________________ Additional Suspension:
    Hydraulic swing phase ________ Waist Belt ________ Forkstrap _______
    Hydraulic swing and stance Other ______________________________
    Phase control _______________
    Outside Hinges ______________________ SYMES
    Manual Locking ________________________ Medial Opening ____________________
    Posterior Opening __________________
    Expandable walls __________________
    Other, specify ______________________
    ANKLE-FOOT
    SACH ________________________________________ Tranverse rotation _________________
    Single Axis ___________________________________ Dynamic response (specify name)
    Multi Axis (specify name) _____________________ ____________________________________
    Other ______________________________

    NOTE SPECIAL FEATURES: End bearing, alignment problems, contractures, etc. ______
    _______________________________________________________________________________________
    _______________________________________________________________________________________
    Number of training periods recommended: _____________________________________________
    Prosthetic Socks: # _____ Ply _____ Wool _____ Cotton _____ Other ___________________
    REMARKS: ___________________________________________________________________________
    Prosthetic Facility: __________________________________ M.D. ____________________________

    DMS-651 (3/00)

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