TT Diagnostic Socket Work Order

Transtibial Diagnostic Socket Order Form

(269)-615-1643 | john@wamhoffmobilitylab.com
Order Information
Patient Name*
Side*
Height
Weight*
Age
Sex
K-Level
Practitioner*
Facility & Location*
Clinic Name and City
Phone/Email
Enter preferred contact method
Ship to Address*
Enter the address the finished socket should be shipped to
Date Ordered

MonthDayYear
Date
Requested Date Needed

MonthDayYear
Date
PO
Enter a PO if you would like, this is for your records.
Measurements
Circumference at MPT (over liner)
Circumference at 1" below MPT (over liner)
Circumference at 2" below MPT (over liner)
Circumference at 3" below MPT (over liner)
Circumference at 4" below MPT (over liner)
Circumference at 5" below MPT (over liner)
Circumference at 6" below MPT (over liner)
Circumference at 7" below MPT (over liner)
Circumference at 8" below MPT (over liner)
Condylar ML
Proximal ML
AP at MPT
MPT to Distal Tibia
Residual Limb Length
MPT to floor
Thigh Circumference
Socket Specifications
Model Type
Select type of cast/model that is being sent to WML
Socket Design/Modifications
Select style of transtibial socket you would like to have fabricated.
Modification Notes
Enter any pertinent details or requests for modification. If the model sent to WML is already modified, please select a "with modifications" option in the Model Type question and enter "Already modified" in this section.
Plastic Type
Select type of plastic for diagnostic socket. If left blank, Bulldog plastic will be used.
Plastic Thickness
Select thickness of plastic for diagnostic socket. If left blank, WML will decide thickness based on size and activity level.
Vacuum Forming Method
Select vacuum forming method. If left blank, model will be bubble/blister formed.
Reinforcement
Select reinforcement method if desired. If left blank, no reinforcement will be provided.
Additions
Socket Insert
Select socket insert material. If no socket insert is desired select none or leave blank.
Socket Insert Thickness
Select socket insert thickness. If no socket insert is desired select N/A or leave blank.
Other
Enter any unlisted addition desired to this space. If nothing else is desired, leave blank.
End Pad
Select end pad material. If no end pad is desired select none or leave blank.
End Pad Thickness
Select end pad thickness. If no end pad is desired select N/A or leave blank.
Posterior Flexible
Select posterior flexible material if desired. A posterior flexible is flexible material only present for the proximal-posterior trimlines. If no posterior flexible is desired select none or leave blank.
Suspension
Lock
Select type of lock desired for the diagnostic socket. If no lock is desired select none or leave blank.
Valve
Select type of valve desired for the diagnostic socket. If no valve is desired select none or leave blank.
Vacuum
If utilizing a vacuum suspension for the diagnostic socket, enter the type of vacuum pump/system being used here. Otherwise, leave blank.
Other
Specify any other suspension methods desired (i.e. ClickReel, anatomical, medial brim), otherwise leave blank.
Finishing
Trimlines
Select method of trimlines desired for the diagnostic socket.
Posterior Shelf
Select posterior shelf shape.
Patellar Trimline Height (distance above MPT)
Enter height of anterior trimline above MPT.
Coronal (Wings) Trimline Height (distance above MPT)
Enter height of medial and lateral trimlines above MPT.
Alignment
Socket Set Up*
Select option for how you would like the diagnostic socket to be finished and sent to you. If an attachment block and/or componentry is selected, please enter desired alignment below; if alignment is not entered standard BK bench alignment will be provided.
Socket Flexion (degrees)
Enter socket flexion (if applicable).
Coronal Angle (degrees)
Specify AB (ABduction) or AD (ADduction)
Rotation Angle (degrees)
Specify IR (Internal Rotation) or ER (External Rotation)
Sagittal Position
Specify sagittal position of socket in relation to the prosthetic foot.
Coronal Position
Specify coronal position of socket in relation to the prosthetic foot.
Components

This section can be left blank if you have chosen to receive just the socket.
Socket Attachment
Please select desired attachment block for socket if desired.
Component Method
Select manner in which components are provided for the diagnostic socket.
Component Provider
Select desired component provider. APC and Trulife are WML standard and stocked.
Component Material
Select desired component material.
4-Hole Attachment
Select desired 4 hole connector.
Prosthetic foot
Enter prosthetic foot being used for this patient
Notes
Notes
Enter any pertinent notes, information, or requests in this section.
Should be Empty:

Transtibial Diagnostic Socket Order Form

Order Information

Measurements

Socket Specifications

Additions

Suspension

Finishing

Alignment

Components

Notes