PH-PD-00006F1: BK Assessment Chart

Patient Name: Page 1/2

BK Assessment Form
rev.5 (2024, Apr, 24)

Patient Number 202 - Date of Assessment

Gender F M DOB/Age Height Weight
Diabetic Y N Revision Y N Date of Amputation
Instalimb staff Name
Amputated reason: Congenital Accident: Diabetes: Cancer: Other( )
Subjective Assessment
SOCIAL HISTORY DEVICE HISTORY
Does the patient have an active lifestyle before First device? Yes / NO
being and amputee?
If "NO", please answer followings...
1. How long does the patient use the device?
What job did he/she do before amputee?
2. What is problem with the current device?

MEDICAL HISTORY PATIENT GOALS/PROSTHETIC GOALS

What does the patient use to go other place? (Ex. Will use for only stand or walk in house? Yes / No
Wheelchair, crutches, etc.)
What job will the patient do with our FD?

What hobby will the patient do with our FD?

OBJECTIVE ASSESSMENT
General Stump Condition General Sound Limb Condition
1. Wound : 1. Skin Condition:
2. Scars : 2. Wound:
3. Neuroma : 3. Pain:
4. Bonny End : 4. Other Amputation:
5. Pain : 5. Effect from stroke:
Sensation and Proprioception Upper Limb (arm) Condition
1. Does the patient have feeling of touch on stump? 1. Can the patient available his/her arm?
(Are there concern of weak sense due to the diabetic?)
2. If cannot use due to amputee or anything, check
the support.
Contractures / joint status if there is concern 2.1 Does the patient get companion help?
1. For the hip contructure or dislocation

2.2 Can the patient use the crutch or anything?

2. For the knee contructure or dislocation

INSTALIMB SOLUTIONS PHILIPPINES INC. USE ONLY

PH-PD-00006F1: BK Assessment Chart

Patient Name: Page 2/2

BK Assessment Form
rev.5 (2024, Apr, 24)
measurement result (Unit: cm)

Day(D/M/Y) / / / / / / / / / / / /
Process
(A) SC
(B) MP
(C) MPT
circumference

(D) FH
(E) ☐MT or
☐ 6cm from PTB
(E') ☐MT or
☐ 9cm from PTB
(E'') ☐MT or
☐ 12cm from PTB
(F) TE
Hip Fx angle
Knee angle
Bony Tibial End Bottom Extension mm Sensitive (part: )
Device type: Premier Pro Lite
Scan condition : Pin Liner Cushion liner No liner Size or other:
Other note High Suspension Knee Sleeve

INSTALIMB SOLUTIONS PHILIPPINES INC. USE ONLY