Logo of the Partner or Center

1. Patient No Prosthesis Orthosis Patient Name ( National Language) Patient Name ( English) Wheelchair Physio Other Logo of the Partner or Center Name of the Center ( National Language) Name of the Center ( English)

2. REGISTRATION (1) & (2) No Yes Yes by Active Passive Dead Discharge Waiting List A B C D E F Patient No Date of birth Name Usual Name Registration Date Address (level 4 ) Address (level 1 ) Married Male Female National ID Card Number Address (level 2 ) Status at the time of injury Address (level 3 ) Military Civilian Present Status Fitted before Actual Status Military Civilian Referred from

3. Cause of Amputation AMPUTEE Congenital Infection Inflammation Vascular Neurological Genetic Tumor ED PH SD TH TR WD ED PH SD TH TR WD HD KD PF TA TF TT HD KD PF TA TF TT TR/W/mine TR/W/gun shot TR/ W/shelling TR/ W/bomb TR/ W/burn TR/ W/other TR/ gun shot TR/burn TR/ traffic acc TR/work acc TR/Animal bite TR/other Amputation Date Place of Injury Country/state of Injury Level of Amputation Upper L Upper R Lower L Lower RL Hospital of Amputation

4. NON AMPUTEE Diagnose Cause of Disability TR/W/mine TR/W/gun shot TR/ W/shelling TR/ W/bomb TR/ W/burn TR/ W/other TR/ gun shot TR/burn TR/ traffic acc TR/work acc TR/Animal bite TR/other Burns Club foot. Cerebral Palsy Fracture Muscular Dys. Spina Bifida Multiple Sclero. Diabetes Leprosy Poliomyelitis Hemiplegia Paraplegia Tetraplegia Quadraplegia Monoplegia Arthritis Scoliosis Kyphosis Lordosis Contractures Dislocation Subluxation Malaria Elephantiasis Tendin Rupt. Nerve Injury Congenital Def. Other C4 C5 C6 C7 C8 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 S1 S2 Level of disability Upper L Upper R Congenital Infection Inflammation Vascular Neurological Genetic Tumor ED PH SD TH TR WD ED PH SD TH TR WD Hip Knee Ankle Foot Thigh Leg Hip Knee Ankle Foot Thigh Leg Lower L Lower RL Place of Injury Country/state of Injury Level of Spinal injury Hospital of Amputation

5. Other Medical Problems Social Environmental conditions Living Environment Current Occupation Seeing Difficulties Hearing Difficulties Speech Impair Mute Blind Deaf Cleft Palate Skin Condition Mental Retardation Rural dry Rural wet Urban dry Urban wet Mountain Forest Armed Forces Farmers, fishermen Non-qualified worker Technician Other Professional Office workers Retired Unemployed and not active Student Other Dormitory Out Total In Notes

6. HD TF/QUAD TF/QUAD/SUCT. TF/NML TF/NML/SUCT. PFFD (CONGE.) KD/ PUSH FIT KD/ SIDE BAR KD/ AntPost OP TT/ PTB TT/ PTB SC TT/ PTB SC SP TT/ SIDE BAR TA/ SYMES TA/ CHOPARD PROSTHESIS No PF/ LISFRANC PF/ Trans MET SD/ COSMETIC SD/ FUNCTION. TH/ COSMETIC TH/FUNCTION. ED/ COSMETIC ED/FUNCTION. TR/ COSMETIC TR/FUNCTION. WD/ COSMETIC WD/FUNCTION. TC (CARPAL) LEFT RIGHT _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ Volume Change Volume Change + Other Components Breakdown Alignment Problems Socket crack/ breakdown Growth Accident False info Wear Stolen, Lost Patient No Diagnose Name Amputee UL UR LL LR Non Amputee UL UR LL LR SP Casting/ Meas. Date Delivery Date Follow up Date Admission Date Fitting Date Replace Date Side Prosthetic type Technician P&O Replacement cause

7. Body Weight Body Height Foot Size Heel Height Kg cm cm mm Beige Olive Terra Barefoot Flip Flop Open Closed Bare Foot / Flip Flop Type Shoe type PTB PTB-SC PTB-SC-SP QUAD QUAD SUC PTB Strap 8 Strap Medium left Small left Medium Right Small Right 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Silesian Belt Suction Supracondylar Small Left Beige Small Right Beige Small Left Olive Small Right Olive Small Left Terra Small Right Terra Medium Left Beige Medium Right Beige Medium Left Olive Medium Right Olive Medium Left Terra Medium Right Terra Adult Left Adult Right Working Ring Elbow Adult Beige Elbow Adult Olive Elbow Adult Terra Pyramidal Adaptor M 10 Pyramidal Adaptor M 8 Adaptor Tube Tilt 20 Degrees EVA PP None Demining Fabrication Information Body Measures Patient Foot Prosthetic Foot Foot Color Footwear Type Prosthetic Foot Size Foot Type Type of Socket Elbow Characteristics Soft Socket Hook Characteristics Knee Characteristics Type of Suspension Hand Characteristics Hip Characteristics Type of Cosmetic

8. Repair No Cos. hand repaired Cos. hand replaced Hook repaired Hook replaced Work. ring repaired Work. ring replaced Worn out Forefoot broken Sole crack Loosening of keel Keel broken Foot noise TF socket cup Convex disc Conical extension cup TT socket cup Socket bolt Silesian belt replaced TH harness repaired TH harness replaced TR harness repaired TH harness replaced PTB strap repaired PTB strap replaced 8 strap repaired 8 strap replaced Silesian belt repaired PP socket repair PP socket replaced Welding seam repair Soft socket repair Soft Socket replaced Socket cup PP Friction rubber Elbow shell PP Forearm Joint Lock mechanism Wrist Unit Repair of PP Replacement of PP Repair of EVA Replacement of EVA ______________ ______________ ______________ ______________ Complete knee Knee shell Knee axis Knee axis bolt Knee lock (PP) Friction washers Calf pipe Securing bolts M6x6 Concave Cylinder Ankle convex disc Ankle concave disc Ankle bolt Rivets Extension support Kick strap Cables Spring Prosthesis Repair History Date Elbow Joint Cosmetic Foot Suspension Socket Supplier Knee Joint Hook / Hand Alignment System Other Repair

9. ORTHOSIS No LEFT RIGHT _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ Volume Change Volume Change + Other Components Breakdown Alignment Problems Socket crack/ breakdown Growth Accident False info Wear Stolen, Lost CTLSO TLSO LSO SIO SEWHO EWHO EO WHO HO HKAFO KO AFO FO Shoe SO CO AFO PTB Patient No Diagnose Name Amputee UL UR LL LR Non Amputee UL UR LL LR SP Casting/ Meas. Date Delivery Date Follow up Date Admission Date Fitting Date Replace Date Side Orthosis type Technician P&O Replacement cause

10. PP Ankle Joint Child Tamarak adult Tamarak child Stirup Adult 20mm Stirup Child 16mm PP Ankle Joint Body Weight Body Height Foot Size Heel Height Kg cm cm mm Barefoot Flip Flop Open Closed CRE Drop Lock Adult 20mm CRE Drop Lock Child 16mm Drop Lock Adult 20mm Drop Lock Child 16mm Swiss Lock Adult 20mm Swiss Lock Child 16mm Adult Child Plastic Conventional Fabrication Information Ankle Joint Characteristics Body Measures Patient Foot Footwear Type Knee Join t Characteristics Hip Joint Characteristics Type of Construction

11. Repair No Knee Joint Hip Joint Others Repairs Suspension Joint replaced Axis / bolt replaced Nut / clip replaced Washer replaced Bearing replaced Lock mechanism replaced Joint replaced Axis bolt replaced Nut/clip replaced Joint replaced Axis / bolt replaced Nut / clip replaced Washer replaced Spring replaced Strap replaced Knee cap replaced Knee cap repaired Side bars replaced Side bars repaired Leather replaced Rivets Ankle Joint Orthosis Repair History Date

12. WHEELCHAIR No Backrest Modified Footrest Modified Armrest Modified Frame Modified Wheel Modified Seat modified Body Weight Body Height Molded Modular Kg cm A A A A A A A A Volume Change Volume Change + Other Components Breakdown Growth Accident False info Wear Stolen, Lost A A A A A A A A Patient No Diagnose Name Amputee UL UR LL LR Non Amputee UL UR LL LR SP Casting/ Meas. Date Delivery Date Follow up Date Admission Date Fitting Date Replace Date Brand Size Replacement cause Wheelchair serial Number Wheelchair modification information Body Measures Seating System

13. Repair No Frame Cushion Seat Wheel replaced Rim Tyre Tube Footrests repaired Armrests repaired Handles repaired Brakes repaired Footrests replaced Armrests replaced Handles replaced Brakes replaced Spoke Bearing Axis Seat replaced Seat repaired Cushion replaced Cushion repaired Rivets Nuts /Bolts Tube Welding Wheel replaced Tyre Bearing Axis Wheelchair Repair History Date Big Wheel Others Repairs Small Wheel

14. Physiotherapy Treatment No Follow -up Pre fitting Post fitting Gait training Others _____________ _____________ _____________ _____________ _____________ _____________ Physiotherapy type Start Finish Sessions Duration Notes / Remarks Patient No Diagnose Name Amputee UL UR LL LR Non Amputee UL UR LL LR SP Physiotherapist in charge Assessment Date Contractures

15. Too long Inappropriate treatment Patient Location change Patient work change Patient Condition change Unknown Abandoned Assessment Date Follow -up Pre fitting Post fitting Gait training Others Physiotherapy type Start Finish Sessions Duration Physiotherapy treatment History Treatment Modification No Physiotherapist in charge

16. Elbow Axillary Cane Walking frame _____________ _____________ _____________ _____________ _____________ _____________ Pair Unit Adult Child Referal date Referal to Referal Reason Orthopaedic consultation Nursery care Medical care Stump revision Orthopaedic surgery Others Patient No Diagnose Name Other Amputee UL UR LL LR Non Amputee UL UR LL LR SP Walking Aids Delivered Delivery date Type Size Pair/Unit Referal Services