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 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/ImpressionDiagnostic Socket
Modifications

No ModificationsNeeds Modifications
Modification Notes
Plastic Type

BulldogOrfitrans StiffVivakCoPolyThermolyn
Flexible Inner Material

Pe-LiteBockliteProflexOPTek FlexOrfitrans ExcelProflex w/ SiliconeOPTek Flex ComfortOrfitrans Extra Soft w/ SiliconeNorthvane
Distal End Pad Thickness

1/8" / 3mm3/16" / 5mm1/4" / 6mm3/8" / 8mm10mm1/2" / 12mm15mm
Distal End Pad Material

PlastazoteBock-LitePe-LiteSilicone
Lock

Coyote AirLockCoyote EasyOff LockBulldog 3Genesis (Puck Lock)Bulldog APLFillauer Shuttle LockOssur Icelock 621Ossur Icelock 4-HoleOssur Icelock 562 HybridOther
Valve (Threaded)

KISSBK LynOssur 551Ossur VacuValveCypress Adaptive AriaOther
Valve (Distal Expulsion)

Bulldog TP5Ossur Icelock 544Cypress Adaptive Aria HV PlateOther
Revo/Click Reel

Panels drawn on model3 Panel (Gastroc + Tibs)Other
Trimlines

StandardDrawn on ModelOther
Socket Attachment

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

HiTek (Aluminum)Willowwood (composite)Bulldog (aluminum or stainless steel))Bulldog (Delrin)3-Prong4-ProngOther
Alignment

Bench AlignmentOther
Notes
Should be Empty:

Transtibial Diagnostic Socket Order Form

Order Information

Measurements

Fabrication Instructions