Patient Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Waist circumference (cm)
Thigh circumference (cm)
Hips circumference (cm)
Ankle circumference (cm)
Calf circumference (cm)
Length of leg (cm)
Compression Sock #1
Brand #1
Style #1
Colour #1
Qty #1
Compression Rating #1
Compression Sock #2
Brand #2
Style #2
Colour #2
Qty #2
Compression Rating #2
Compression Sock #3
Brand #3
Style #3
Colour #3
Qty #3
Compression Rating #3
Compression Sock #4
Brand #4
Style #4
Colour #4
Qty #4
Compression Rating #4
Compression Sock #5
Brand #5
Style #5
Colour #5
Qty #5
Compression Rating #5
Compression Sock #6
Brand #6
Style #6
Colour #6
Qty #6
Compression Rating #6
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