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.
How to use the Prosthetics and Orthotics Device Medical History
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Prosthetics and Orthotics Device Medical History from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Prosthetics and Orthotics Device Medical History in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 19 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Prosthetics and Orthotics Device Medical History HIPAA compliant?
Yes. All Formisoft templates, including the Prosthetics and Orthotics Device Medical History, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 19 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Prosthetics and Orthotics Device Medical History is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Prosthetics and Orthotics Device Medical History for your practice. Set up in minutes.
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