cti patient data form
patient cast
cad file (aop)
cms
dms file
required patient information
last name:
first name:
phone:
height:
cm
ft
weight:
in.
prescribed by:
/
kg
age:
/
name
specialty
degrees of extension to be installed (Default is 0-10°):
sex (m/f):
lbs
0
5
10
15
phone
flexion stop kit (0-90) install:
20
diagnosis/symptom:
left knee
right knee
bilats
please specify cti model, then select additional needs - a color must be specified
cti model:
colors:
custom designs:
options:
Default is black
vapor
oa Default is 4 degrees
standard
Medial
pro sport
Lateral
pcl (kit will be added)
Additional fee
super short
Recommended for 5’3” or less
Additional Fee
Matt
Shiny
Hisbiscus
Sports Equipment
D-rings on outside of brace
Yellow
Silver
Flag
Camouflage
D-rings on inside of brace
Sky Blue
White
Flames
Single Color
Ocean Blue
Champagne
Metal
2-color Fade
Riveted on the inside of brace
Navy Blue
Pink
Sponge
2-color Half & Half
Riveted on the outside of brace
Black
Red
Celestial
Sports Fan
Screwed on the Inside of brace
Charcoal
Green
Other:
Screwed on the outside of brace
accessories:
MX kit
Patella cup
measurements - all 23 required please. caliper measurement (#23) should be taken first.
Caliper Measurement
(#23) should be taken first
1.
2.
Hinge Width
Hinge Depth
medial
contours
18. Level A
LEVEL A
lateral
measurements
14.
contour
15.
contour
3.
4.
Contour
A-P
5.
6.
Contour
A-P
circumferences
(in cm)
LEVEL B
19. Level B
special conditions
VARUS:
° VALGUS:
Prominent:
VMO
Hockey Quads
Prominent Tibialis Anterior
20. Level C
21. Level E
22. Distal Border of Patella
Prominent Fibularhead
RTM (Rounded Tibial Member)
Osgood-Schlatters Disease
Shorten Femural Component
0,5”
Contour
A-P
Tibia
LEVEL C
10.
LEVEL E
© Copyright Össur, August 2013
Össur Europe BV
Ekkersrijt 4106-4114
PO Box 120
5690 AC Son en Breugel
The Netherlands
tel
fax
1,0”
1,5”
Check to receive with initial order, free of charge:
AMS Wrap:
Neoprene
contour
ski boot measurement
[Required for Ski Boot Attachment]
17.
contour
address
1,5”
new mandatory order information required
16.
Tibia
Contour
A-P
Tibia
0,5”
23.
caliper measurement at joint
space [1.6-2.0cm less than #1]
Take measurement in a weight
bearing position at full extension
LEVEL D
11.
12.
13.
1,0”
Shorten Tibial Component
joint space
7.
8.
9.
°
VLO
+31 (0) 499 462 840
+31 (0) 499 462 841
cm / in from the
distal border of the patella
to the top of the ski boot
Attachment not available if
the measurement is less than
7 inches
e-mail
web
[email protected]
www.ossur.com
Evazote
Sof Sleeve
special instructions
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