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Patient Evaluation Supplement
Patient Evaluation Supplement
Name
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Last
Height/Weight
Condition/Injury Description
Please list any past or current diagnos(e)s
Injury/Relevant Surgeries and Date(s):
Comorbidities (check all that apply):
Asthma
Back Pain
Buerger's Disease
Cerebral Palsy
Cerebrovascular Accident (Stroke)
COPD
Congestive Heart Failure
Coronary Artery Disease
Coronary Heart Disease
Diabetes Mellitus
Multiple Sclerosis
Muscular Dystrophy
Myocardial Infarction (Heart Attack)
Obesity
Osteoarthritis
Osteomyelitis
Osteoporosis
Parkinson’s Disease
Peripheral Artery Disease
Peripheral Vascular Disease
Peripheral Neuropathy
Renal Failure (Kidney Failure)
Respiratory Failure
Rheumatoid Arthritis
Sciatica
Shortness of breath
Tuberculosis
Vascular Disease (Heart Disease)
Venous Insufficiency
Muscular Dystrophy:
Other:
Other Comorbidity Description
Muscular Dystrophy Description
Medications
WHAT MOBILITY/INDEPENDENCE GOALS WOULD YOU LIKE TO ACHIEVE WITH PROSTHETIC/ORTHOTIC TREATMENT?
Identify All That Is True To Help Us Identify A Proper Treatment Plan
Strength / Mobility
Falls are never an issue
Near-falls are an issue for me
I currently use a prosthesis or orthosis (brace)
I have used a different prosthesis or orthosis in the past
I currently use an assistive device (walker, cane, crutches, etc)
I have used an assistive device in the past
I currently attend physical therapy
Other:
Other Strength/Mobility Description
Difficult Walking Conditions For Me Include
Uneven terrain
Ascending / descending stairs
Ascending or descending hill / ramp
Snow / Ice
Other:
Other Walking Conditions Description
Work Details
I am currently working
I am currently not working
My Job requires use of stairs
My job requires prolonged standing
My job requires walking long distance or duration
My job includes difficult walking conditions
My Job Is:
My Daily Activities Include
Shopping
Preparing Meals
Cleaning My Home
Performing Yardwork
Walking the Dog
Other:
Other Daily Activities
Living Situation
I live alone
I live with a
I care for children at home
I must use stairs at home
There are difficult walking conditions around my home
Relation to others I live with
My Hobbies / Other Activities Include
Long walks
Hiking
Running
Gardening
Other:
Other hobbies / activities
Signature
Patient / Guardian Print Name
Relationship to Patient