Company
FreeWalk™
Stance Control KAFO
Account #
Order Form
Practitioner
Mailing Address
Phone
For clinical questions call 800 328 4058.
Note: FreeWalk does not include a foot plate.
Fax
Shipping Options:
Email Address
UPS Next Day
Patient Name
PO Number
Requested Due Date
Patient Data
Male
UPS 2–Day
Female
UPS Ground
Other ______________
Date of Submission
Left
Right
Weight __________
Shoe Size __________
Clinical & Counter Indications
All specifications and pricing are subject to change without notice.
5
4
3
2
1
0
Muscle strength of hip flexors (scale 0-5)
5
4
3
2
1
0
Muscle strength of soleus (scale 0-5)
5
4
3
2
1
0
Muscle strength of inverters (scale 0-5)
5
4
3
2
1
0
Muscle strength of everters (scale 0-5)
5
4
3
2
1
0
Not
Suitable
Muscle strength of hip extensors (scale 0-5)
Suitable
©2015 Otto Bock HealthCare LP • 13203 • 5/15
Complete the information below to help determine if the FreeWalkTM is appropriate for your patient.
Unilateral paresis or paralysis
yes
no
Has minimum mobility of ankle joint 10°
yes
no
Flaccid paresis or paralysis
yes
no
Functional control over knee muscles
yes
no
Hyperextension of the knee joint
yes
no
Spasticity
yes
no
Severe instability of the ankle joint
yes
no
Knee-flexion contracture (Passive ROM)
yes
no (A passive knee-flexion contracture below 10° is acceptable.)
Unstable valgus position of the knee when fully extended
yes
Unstable varus position of the knee when fully extended
yes
no (A redressed valgus angle below 10° is acceptable.)
no
Summary of clinical picture _____________________________________________________________________________________________________
Remarks _____________________________________________________________________________________________________________________
Foot plate Options
Foot plate: Laminated
Foot plate: Thermoplastic
Foot plate: Prepreg
Attach foot plate to base? (additional charges will apply)
yes
no
Knee Angle
In case of hyperextension of the knee joint, please indicate the angle ______°
In case of knee flexion contracture, please indicate the angle ______°
For patients that present genurecurvatum, would you like the 2 distal bands reversed?
yes
no
Ottobock Fabrication Services 1130 S. 3800 West, Ste. 400, Salt Lake City UT 84104
For more information please visit our web site at www.ottobockus.com
Page 1 of 2
USA 800 328 4058
Fax 800 810 7994
Email [email protected]
For Casting
For Tracing
FreeWalk
recommended • Position patient on tracing paper with care to pad under seat
and popliteal space as needed to prevent splaying of flesh
practices for
during tracing.
best outcomes • D
elineation tool ensures a good capture of the shape of the limb.
•T
ake a negative impression of the patient’s limb in the
desired corrected position.
• Take care to wrap bandage so you don’t have “roping”
•T
ake care not to position the patient so that the flesh
on the thigh and calf splay during capture.
• If further corrections are needed, make those corrections
to the negative cast before shipping to us.
•W
ith a cast you don’t have to fill in measurements for entries
asking for “Tibia width” and “Tibia height” and “Tibia Angle”.
• Take care to keep toe pointing up in the same position while
doing tracing. A leg that is allowed to rotate during tracing will
alter the finished tracing and product.
• Fill out all measurements on measurement form.
• When taking measurements do not compress flesh.
Leg
circumf.
Please complete both sides
of this form completely.
Attach patient label to
tracing or cast and forward
all to:
*
P1
e
sur
a
Me
Ottobock
Fabrication Services
A–P
P1 to floor
Lateral
ally
gon
dia
P1 to floor Medial
P 2*
1130 S. 3800 West
Ste. 400
Salt Lake City, UT 84104
M–L
Leg
circumf.
M–L
A–P
P2 to
floor
Leg
circumf.
M–L
A–P
P3 to
floor
Leg
circumf.
M–L
A–P
P4 to
floor
Min.
80 mm
Height:
Knee center height
is determined by
measuring 2 cm above
medial tibial plateau.
Min.
80 mm
P 3* **
If you have any questions,
please call 800 328 4058.
Tibia
width
Tibia
height
Tibia
angle
Tibial crest
P 4*
P1-P4 to floor = horizontal band height
Min.
100 mm
Tibial Crest measurement
=
distance between lateral
side and tibial crest
Height:
lateral malleolus
1. Contour drawing frontal view.
647F136=D – 08.07
Short Instructions for Taking Measurements
2. Mark patella, knee center, medial and lateral malleolus.
3. Mark P1 40 mm below the perineum. Use a measuring tape to measure thigh
circumference, then use a caliper to measure height and width of the femur
at that point. Measure the distance between P1 and sole plate.
Otto Bock HealthCare GmbH
Max-Näder-Straße
4. Mark P2 60 mm above the upper edge of the
patella. 15 · 37115 Duderstadt · Telefon 05527 848 3030 · Telefax 05527 848 1585 · [email protected] · www.ottobock.de
Continue as with P1.
5. Mark P3 approx. 60 mm below the patella edge. If the fibular head can be palpated
here, position the pad retainer more distally. Continue as with P1 and P2.
Measure tibia width (middle of tibia to lateral side) and tibia angle.
The pivot point of the goniometer should be aligned vertically with
the tibial crest. The marks on the goniometer should touch the leg
on the medial and lateral sides. Select the desired pad retainer.
6. Mark P4 80 mm above the malleolus. Take same measurements as P1 and P2.
7. Contour drawing sagittal view.
8. Determine the height of the tibial crest (see drawing).
Ottobock Fabrication Services 1130 S. 3800 West, Ste. 400, Salt Lake City UT 84104
For more information please visit our web site at www.ottobockus.com
Page 2 of 2
USA 800 328 4058
Fax 800 810 7994
Email [email protected]