Prosthetics and Orthotics Device Medical History
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Prosthetics and Orthotics Device Medical History
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This prosthetics and orthotics medical history form provides comprehensive documentation for certified prosthetists and orthotists (CPOs) evaluating patients for assistive devices. The form systematically captures amputation etiology and level, surgical history, healing status, and residual limb characteristics essential for proper device design and fitting. For orthotic patients, it documents the specific musculoskeletal condition, deformity type, pain patterns, and functional limitations requiring bracing or support devices.
The template includes detailed sections on previous device experience, including what worked well and problems encountered with past prosthetics or orthotics. It assesses current mobility level, transfer abilities, living environment, and occupational or recreational activities that will influence device prescription. The form captures skin integrity concerns, sensation changes, circulation status, and comorbidities like diabetes that affect healing and device tolerance. It documents insurance coverage for durable medical equipment, measurement specifications, and patient goals for device function whether basic ambulation, return to work, or athletic performance.
What's included
- Amputation level, side, and date
- Etiology of amputation or limb difference
- Surgical history and healing status
- Residual limb measurements and characteristics
- Previous prosthetic or orthotic devices used
- Current mobility and transfer abilities
- Living environment and accessibility
- Skin integrity and sensation assessment
- Comorbidities affecting device tolerance
- Occupational and recreational activity goals
- Insurance and DME coverage information
- Pain and phantom sensation history
Who uses this template
- Prosthetics and Orthotics Clinics
- Rehabilitation Centers
- Limb Loss Centers
- Hospital O&P Departments
- Veterans Affairs O&P Services
All form fields
9 fields across 3 pages. Customize any field after signing up.
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