Certified Peer Visitor Report Form
All information is considered confidential. This information will be used by the Amputee Coalition to document the peer visit as
well as to follow-up with amputees interested in being contacted by the Amputee Coalition. No personal information will be
shared at any time.
Instructions: Please complete this form and submit via email, mail, or fax. You may also complete an electronic version located
on the peer visitor section of our website. Please complete after every visit conducted as a peer visit.
Peer Visitor:
Date of Peer Visit:
Peer Visitor Email:
Location of Peer Visit:
Referred by:
New Amputee Information:
Name:
Date of Amputation:
Gender:
Male
Approximate Age:
Female
Ethnicity:
Caucasian/White
Black/African American
Asian/Asian American
Latino/Latina
Native American
Other
Address:
City:
Phone:
State:
Zip:
Knee Disarticulation
Shoulder Disarticulation
Symes
Toe
Wrist Disarticulation
Forequarter
Email:
Type of Amputation:
(check all that apply)
Above Elbow
Above Knee
Below Elbow
Below Knee
Finger(s)
Foot
Hand
Hemipelvectomy
Hip Disarticulation
Site of Amputation: (check all that apply)
Cause of Amputation:
Diabetes
Left
Cancer
Requested follow-up: by Amputee Coalition
If yes, preferred method of contact:
Right
Email
Bilateral
Infection
Yes
No
Mail
Trauma
/
Other
Other
Congenital
by Peer visitor
Phone
Additional information (including specific information requested for follow-up):
[email protected] | Phone: 888-267-5669 | Fax: 865-525-7917
900 East Hill Avenue, Suite 390 | Knoxville, TN 37915
Yes
Other
No