Patient Evaluation Supplement

Patient Evaluation Supplement
Name
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):
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
Other Strength/Mobility Description
Difficult Walking Conditions For Me Include
Other Walking Conditions Description
Work Details
My Job Is:
My Daily Activities Include
Other Daily Activities
Living Situation
Relation to others I live with
My Hobbies / Other Activities Include
Other hobbies / activities
Signature
Patient / Guardian Print Name
Relationship to Patient

Identify All That Is True To Help Us Identify A Proper Treatment Plan