5.2 Measurement form
Otto Bock HealthCare GmbH · Max-Näder-Str. 15 · 37115 Duderstadt
T +49 5527 848-3030 · F +49 5527 848-1585 · [email protected] · www.ottobock.com
Contact
Customer
number
Date
Customer
Shipping address
Company
Company
Street
Street
Postal code/city
Postal code/city
Phone
Patient ID
Measurement Form for Polyurethane (PUR) Liner
Transtibial and Syme amputations
Right
Exterior coating
g
n
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t
a
o
c
e
l
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t
x
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W
1.6 mm, colour:
Skin colour
or
Black
0.6 mm, colour:
Skin colour
or
Black
1.0 mm, colour: Silver
Without textile coating
(requires a non-adhesive coating)
Y
G
O
L
O
N
H
C
E
T
D
R
A
U
G
N
I
K
S
6Y400
PUR custom liner from plaster cast and
measurement form
6Y400=M
PUR custom liner from measurement form
6Y416
Shape Plus PUR custom liner from
plaster cast and measurement form
k
s
a
h
c
u
s
s
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f
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m
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s
a
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t
s
a
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t
s
a
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p
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t
f
I
nee flexion > 15°,
a bulging, eccentric or concave residual limb end, pronounced
invaginated scar tissue or excess size (length > 50 cm, circumference
> 50.5 cm), a 6Y416 Shape Plus Liner is required.
:
r
e
n
i
l
m
o
t
s
u
c
t
n
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m
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c
a
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p
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R
please contact customer service.
n
o
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l
b
i
s
s
o
p
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r
a
%
0
1
±
f
o
s
e
c
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a
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e
l
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t
s
s
e
n
k
c
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h
t
ll
a
W
subsequent orders.
o
f
e
li
f
a
s
a
a
t
a
d
t
s
a
c
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t
s
a
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k
c
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b
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O
r two years after the
most recent order.
Wall thickness
m
r
o
f
i
n
U
(with 13 mm distal cushion)
(Wall thickness:
4 mm
5 mm
6 mm)
d
e
r
e
p
a
T
(6 mm wall thickness at knee centre tapering to
Width of the distal residual limb end
mm
(if deviating from 13 mm)
Distal connector
t
u
o
h
t
i
W
h
t
i
W
(requires the selection of a textile coating)
Comments:
MPT
+ 100 mm
+ 50 mm
+ 50 mm
+ 100 mm
+ 150 mm
+ 200 mm
+ 250 mm
Minimum
circumference
mm
Maximum
circumference
mm
Residual
limb length
mm
Lower leg measurements
Extend the measurement sections if necessary.
Ottobock | 31
Harmony System
Appendix
Содержание Harmony P3
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