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CAD Measurement Chart

PATIENT INFORMATION:
* = Required      
Patient's Name:* Sex: Amputation Type:
Patient ID# Age: Height:   Weight:
Casting Date: Due Date:
Account # P.O. #
Facility:* Practitioner:*
Bill to:*
Ship to:*
 

   

ORDER DESCRIPTION

  
Device Measurement & Details
AK
 3S Size

Others Measurements Taken Over Liner
Liner Type: L-A-P:
M-A-P: Soft M-L at 1" Level:
I.T. To:
Distal Tip of Sleeve Nipple: With Elongation:
Distal End of Residual Limb: Distal End of Femur:
Circumference at I.T.
Circumference at:
1"
7"
2"
8"
3"
9"
4"
10"
5"
11"
6"
12"
Description:
 
 Measurements

Length:

1.
2.
3.
4.

 

General Musculature:




Brim Shape:






Socket Flexion:

Socket Add:

Prosthetic Measurements:
Prosthetic Measurements

Length:

1.
2.
3.
4.
5.
6.
7.

Socket:
Suspension:
Prosthetic Measurements:
Prosthetic Measurements Length:

1.
2.
3.
4.
5.
6. 		Knee:
Foot:
Components