Transtibial Diagnostic Socket Order Form
(269)-615-1643 | john@wamhoffmobilitylab.com
Order Information
Patient Name
*
PO
Date
/
Month
/
Day
Year
Date Needed
/
Month
/
Day
Year
Practitioner
*
Phone/Email
Facility
*
Address
*
Side
*
Please Select
Right
Left
Bilateral
K-Level
Please Select
K1
Low-level K2
High-level K2
Low-level K3
High-level K3
K4
Height
Weight
*
Age
Sex
Please Select
Male
Female
Unspecified
Measurements
Circumference at 4" / 10cm above MPT
Circumference at 3" / 7.5cm above MPT
Circumference at 2" / 5cm above MPT
Circumference at 1" / 2.5cm above MPT
Circumference at MPT
Circumference at 1" / 2.5cm below MPT
Circumference at 2" / 5cm below MPT
Circumference at 3" / 7.5 cm below MPT
Circumference at 4" / 10cm below MPT
Circumference at 5" / 12.5cm below MPT
Circumference at 6" / 15cm below MPT
Circumference at 7" / 17.5cm below MPT
Circumference at 8" / 20cm below MPT
Condylar ML
Proximal ML
AP at MPT
MPT to Distal Tibia
Residual Limb Length
MPT to floor
Thigh Circumference
Fabrication Instructions
Model Type
Cast/Impression
Diagnostic Socket
Modifications
No Modifications
Needs Modifications
Modification Notes
Plastic Type
Bulldog
Orfitrans Stiff
Vivak
CoPoly
Thermolyn
Flexible Inner Material
Pe-Lite
Bocklite
Proflex
OPTek Flex
Orfitrans Excel
Proflex w/ Silicone
OPTek Flex Comfort
Orfitrans Extra Soft w/ Silicone
Northvane
Distal End Pad Thickness
1/8" / 3mm
3/16" / 5mm
1/4" / 6mm
3/8" / 8mm
10mm
1/2" / 12mm
15mm
Distal End Pad Material
Plastazote
Bock-Lite
Pe-Lite
Silicone
Lock
Coyote AirLock
Coyote EasyOff Lock
Bulldog 3Genesis (Puck Lock)
Bulldog APL
Fillauer Shuttle Lock
Ossur Icelock 621
Ossur Icelock 4-Hole
Ossur Icelock 562 Hybrid
Other
Valve (Threaded)
KISS
BK Lyn
Ossur 551
Ossur VacuValve
Cypress Adaptive Aria
Other
Valve (Distal Expulsion)
Bulldog TP5
Ossur Icelock 544
Cypress Adaptive Aria HV Plate
Other
Revo/Click Reel
Panels drawn on model
3 Panel (Gastroc + Tibs)
Other
Trimlines
Standard
Drawn on Model
Other
Socket Attachment
Socket only
Socket w/ attachment plate
Socket w/ attachment plate + reinforcement
Socket Attachment Plate
HiTek (Aluminum)
Willowwood (composite)
Bulldog (aluminum or stainless steel))
Bulldog (Delrin)
3-Prong
4-Prong
Other
Alignment
Bench Alignment
Other
Notes
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