TT Diagnostic Socket Work Order

Transtibial Diagnostic Socket Order Form

(269)-615-1643 | john@wamhoffmobilitylab.com
Order Information
Patient Name*
PO
Date

MonthDayYear
Date Needed

MonthDayYear
Practitioner*
Phone/Email
Facility*
Address*
Side*
K-Level
Height
Weight*
Age
Sex
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
Fabrication Instructions
Model Type

Cast/ImpressionDiagnostic Socket
Modifications

No ModificationsNeeds Modifications
Modification Notes
Lamination Layup

Bubble/BlisterDrape
Plastic Thickness

1/4"3/8"1/2" (standard)5/8"
Plastic Type

Bulldog (standard)VivakThermolynCoPolyOrfitrans Stiff
Lock

Lock ProvidedSpecify Lock
Specify Lock
Valve (Threaded)

KISSOssur 551BK LynCypress Adaptive AriaOther
Valve (Distal Expulsion)

Ossur Icelock 544Willowwood Alpha Distal ExpulsionCypress Adaptive Aria HV PlateOther
BOA/Click Reel

Panels drawn on model3 Panel (Gastroc + Tibs)4 Panel (2 Gastroc + TibsOther
Trimlines

StandardDrawn on ModelOther
Socket Attachment

Socket onlySocket w/ attachment plateSocket w/ attachment plate + reinforcement
Socket Attachment Plate

Willowwood (standard)BulldogOssur3-Prong4-ProngOther
Alignment

Bench AlignmentOther
Notes
Should be Empty:

Transtibial Diagnostic Socket Order Form

Order Information

Measurements

Fabrication Instructions