A. Physical Exam
(relevant to functional deficits)
• Weight, height, weight loss/gain
• Cardiopulmonary examination
• Musculoskeletal examination (arm and leg strength; range of motion)
• Neurological examination; gait, balance and coordination
B. History of amputation
• Diagnosis/Reason for amputation(s)
• Date of amputation(s)
• Side of amputation(s)
• Clinical course
• Therapeutic interventions and results
C. Functional Deficits
Symptoms limiting ambulation/dexterity
• Medical history relevant to deficit(s)
• Activities of daily living (ADL) and how impacted by deficit(s)
• Diagnosis causing these symptoms
• Other comorbidities
• Other ambulatory assistance currently used (wheelchair, walker, cane, caregiver, etc. with/without prosthesis)
D. Functional level
Describe patient’s ADL on a typical day in terms of functional capability (see section E for lower extremity)
• Patient’s functional capabilities prior to amputation
• Patient’s current functional capability
• Patient’s expected functional potential with use of the new prosthesis and explanation for the difference (if any)
E. Motivation to use prosthesis
Describe patient’s desire to use the new prosthesis or to ambulate (if lower extremity)
F. Describe the condition of the residual limb
• Is there skin irritation, breakdown, or infection?
• Are limb volume changes occuring?
• Is there swelling, weight fluctuations, or muscle change?
• Is the limb fully healed?
G. Condition/status of current prosthesis/component
Why is a replacement needed?
• If the current prosthesis/component is worn or broken, describe which component needs to be evaluated for repair/replacement
• If the patient’s condition has changed, describe why the current prosthesis/component is no longer appropriate
Examples: skin irritation, limb volume change, weight gain/loss, decreased stability
If the patient’s functional level has changed, describe why the current prosthesis/component will not allow the patient to achieve the desired function (see section D for descriptions)
H. Patient’s past experience with prosthesis
• Which other prosthesis/components have been tried in the past?
• Describe any problems patient expienced (e.g. barriers to ambulation, balance, stumble, inability to perform activities, problems with back or sound side limb)
I. Recommendation for new prosthesis/component(s) based on your functional level evaluation-Section D.
This should be part of your treatment plan. You do not need to specify the brand of device.