Rev. 11/11
LegAssist™ - LCS Custom Measuring Form
PO#:
Contact Name:
Company:
Phone:
Bill-To Address:
Ship-To Address:
Patient:
Foam (check one):
Date:
Sex:
Regular
Advanced (WaveFoam™)
Age:
Ht:
Leg (check one):
Hip Attatchment
(optional - charges apply) (Measurements F & G required)
Wt:
Right
Waist
Left
G
Waist at bottom of belt
Follow contour of limb on all measurements
(All measurments in cm)
Lateral
Length
Medial
Length
Posterior
Length
Anterior
Length
Lateral
Length
Medial
Length
Posterior
Length
Anterior
Length
A1
B1
C1
D1
A2
B2
C2
D2
= Locations measured along lateral aspect
F
Circumference *
Gluteal Fold
Pick a zero point*
Bottom of Garment*
*See instructions
Note: order a LCS Super
if greatest circumference is > 90 cm
49
A1
30 cm
25 cm
20 cm
15 cm
10 cm
5 cm
ø Point
5 cm
10 cm
A2
D1
C1
B1
D2
C2
B2
Approximatley 8-10cm
from bottom of lobule