Prosthestics & Orthostics Form

{if $VIEW != true} {/if}
Therapist   
Involvementget_involvement_left() eq 1}checked{/if}"> Left    get_involvement_right() eq 1}checked{/if}"> Right    get_involvement_bilateral() eq 1}checked{/if}"> Bilateral   
Location of Evaluation{html_options name="location" selected=$prosthesis->get_location() options=$prosthesis->location_array}
Prescription Diagnosis

Hx
get_involvement_bilateral() eq 1}checked{/if}"> Pt has worn a L.E. orthosis in the past 5 yrs.


Item to be Supplied
Model # get_new() eq 1}checked{/if}"> New
Size get_replacement() eq 1}checked{/if}"> Replacement
Measurements
  get_foam_impressions() eq 1}checked{/if}"> Partial Weight bearing Foam Impressions
Shoe Size

Calf    Ankle


Purpose{html_options name="purpose" selected=$prosthesis->get_purpose() options=$prosthesis->purpose_array}      Other:


Notes



get_goals_discussed() eq 1}checked{/if}"> Pathomechanics & Orthotic goals discussed.
get_use_reviewed() eq 1}checked{/if}">  Donning, doffing, skin precautions, and orthotic use reviewed with patient get_wear_reviewed() eq 1}checked{/if}">  Initial wear schedule reviewed with patient.


Product Longeveity And Patient Wearing Schedule Number of years patient has worn an orthosis/prosthesis year(s)
Age of current orthosis/prothesis months or year(s)
Daily wearing schedule hours per day


Clinical Plan get_plan_to_order() eq 1}checked{/if}"> Plan to order orthosis/prosthesis/product and fit on return date:
get_received_product() eq 1}checked{/if}"> Patient has received orthosis/prosthesis/product on this date:
get_given_instructions() eq 1}checked{/if}"> Patient been given instructions for the device/service prescribed, understands the instructions, and is able to demonstrate its appropriate use    get_patient_understands() eq 1}checked{/if}"> Yes


Add Code


       [Don't Save]