Conventional Diagnostic Socket Fabrication
Diagnostic
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Diagnostic
Patient Name:
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First Initial
Last Name
Encounter # / PO #:
*
Practitioner:
*
Clinic Location:
*
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Alpena (786100)
Big Rapids (781800)
Bloomington (317000)
Cadillac (786300)
Carmel (317100)
Charlotte (318500)
Charlotte (477800)
Columbus (317200)
Danville (317700)
Evansville (317300)
Fort Wayne (006100)
Gaylord (786500)
Greenwood (317400)
Holland (016800)
Indianapolis (317500)
Indianapolis (780800)
Indianapolis (785200)
Jackson (013700)
Kokomo (785700)
Lexington (317800)
Lexington (007900)
Livonia (774400)
London (317900)
Louisville I (318000)
Louisville II (318100)
Louisville III (008100)
Marquette (787400)
Monroe (318700)
Mooresville (318800)
Morehead (318200)
Mt. Sterling (318300)
Paducah (000100)
Paducah (318400)
Petoskey (787700)
Portsmouth (006500)
Prestonsburg (007901)
Richmond (475700)
Roseville (772900)
Seymour (317600)
Somerset (028100)
South Bend (765100)
Traverse City (788100)
Waterford (780000)
Other (Approval Required)
Email
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Today's Date:
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-
Month
-
Day
Year
Date
Due Date:
-
Month
-
Day
Year
Date
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Conventional Diagnostic Socket Fabrication
Patient Information
Weight:
*
Age:
*
Affected Side:
*
Left
Right
K-Level:
*
K1
K2
K3
K4
Level:
*
Transtibial
Transfemoral
Type:
*
Vivak (PETG)
Orfitrans Stiff (ThermoLyn)
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Conventional Diagnostic Socket Fabrication
Alignment
Method of Transfer:
*
No Alignment (static fit or alignment to be done in-office)
Neutral (All Planes)
Transfer From Components
Transfer From Lines
I need to make changes to my alignment:
Transverse Changes
Coronal Changes
Sagittal Changes
Transverse Changes:
Please Select
Internally Rotate Foot
Externally Rotate Foot
Number of Degrees:
Coronal Changes (Angular):
Please Select
Abduct Socket
Adduct Socket
Number of Degrees:
Coronal Changes (Linear):
Please Select
Inset Knee/Foot
Outset Knee/Foot
Number of Inches:
Sagittal Changes (Angular):
Please Select
Flex Socket
Extend Socket
Number of Degrees:
Sagittal Changes (Linear):
Please Select
Anterior Shift Foot
Posterior Shift Foot
Number of Inches:
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Conventional Diagnostic Socket Fabrication
Modifications
I need plaster modifications:
*
Yes
No
Decrease Model:
Globally (standard)
Circumferentially
Increase Model:
Globally (standard)
Circumferentially
Amount of Change:
1 Ply
2Ply
3 Ply
5 Ply
Other
Follow instructions on diagnostic socket (for modifications only)
Areas needing plaster mods marked on diagnostic socket
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Conventional Diagnostic Socket Fabrication
Suspension / Distal Attachment
Suspension:
*
None (static fit or being attached in office)
Shuttle Lock
Lanyard
Suction/Vacuum
Suction/Vacuum:
Plate with distal valve included
Valve mounted on the socket
Shuttle Lock:
65mm 4-Hole (Bulldog style)
Bulldog APL (for offsets)
Ossur 562 Hybrid
Coyote AirLock
Other
Coyote Air Lock Depth:
Regular for 8-click pin
Deeper for 11-click pin
Lanyard:
65mm 4-Hole (KISS style)
Delrin Base (for offsets)
RevoLock Align (mark reel location)
RevoLock 4-Hole (mark reel location)
Suction/Vacuum Integrated Plates:
Ossur 544 Plate (includes valve)
Cypress Plate (includes valve)
Tube Cutout (includes barb for hose)
Heavy Duty 450lb Rated (Trulife AAASMP450)
Other
Suction/Vacuum Push Button Auto Expulsion Valves (socket mounted):
Ossur Icelock 551
Aria Valve Plus (CA200-AVPM)
Other
Basic Distal Attachments:
4-Hole Plate (no valve)
Crows Foot (three prong)
Basic 4-Hole Plate:
Standard 9.5mm "low-profile" (Bulldog FHLA-3)
Square Shaped 11mm (Bulldog FHLAS-11)
Heavy Duty 450lb Rated (Trulife AAASMP450)
Crows Foot:
Low-profile 9.5mm crows foot
Deep depth 14mm crows foot (use with OB rotator or similar)
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Conventional Diagnostic Socket Fabrication
Inner Liners
Inner Liner Type:
*
No Inner Liner
Keasy Cone
Bocklite (Tan) 6mm, w/distal pad
Pelite (White) 8mm, w/distal pad
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Conventional Diagnostic Socket Fabrication
Add-Ons and Trim
Amount of Inner Liner Exposed:
*
1/4"
1/2"
1"
Leave 1/4" at Shelf
Leave Flush at Shelf
Add-Ons (as marked):
RevoFit System
Window(s)
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Conventional Diagnostic Socket Fabrication
Notes
I would like a phone call to discuss this project prior to starting fabrication
Yes
Notes:
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