Lower Extremity Prosthetic Fabrication

Transtibial Definitive Socket Fabrication
TT
Patient Name:*

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Encounter # / PO #:*
Practitioner:*
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Today's Date:*

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Due Date:

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Transtibial Definitive Socket Fabrication

Patient Information
Weight:*
Age:*
Affected Side:*

LeftRight
K-Level:*

K1K2K3K4

Transtibial Definitive Socket Fabrication

Alignment
Method of Transfer:*

Neutral (All Planes)Transfer From ComponentsTransfer From Lines
I need to make changes to my alignment:

Transverse ChangesCoronal ChangesSagittal Changes
Transverse Changes:
Number of Degrees:
Coronal Changes (Angular):
Number of Degrees:
Coronal Changes (Linear):
Number of Inches:
Sagittal Changes (Angular):
Number of Degrees:
Sagittal Changes (Linear):
Number of Inches:

Transtibial Definitive Socket Fabrication

Notes
I would like a phone call to discuss this project prior to starting fabrication

Yes
Notes:

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