body jacket measurement form

Print Form
Email Form
BODY JACKET MEASUREMENT FORM
Date:
Due Date:
Contact
Ship To:
Account:
E-mail
Address:
PO#:
Phone:
Ship Via:
Fax:
City:
State
Zip
PATIENT INFORMATION
ORTHOSIS DESIGN
Standard: 3/16" Aliplast, 5/32" LDPE, 15 Degrees Lordosis
Patient Name:
Age:
Sex:
Ht:
Aliplast
Inner Material:
Wt:
Yes
No
Size:
ORTHOSIS INFORMATION
Finished?
LDPE
Outer Material:
Previous wearer?
Measurement:
Cast
Scan
Measure ONLY
Overlaps:
Scan Label:
Transfer on Straps
Color/ transfer:
1/4"
Other:
5/32"
1/8"
Opening:
No
Yes
3/16"
1/8"
Size:
Diagnosis:
Other:
3/16"
1/4"
Anterior
Posterior
Bivalve
Left Lateral
None
Butting
Smooth
Tongue
Right Lateral
Wide Tongue
Glue/ Reinforce Tongue
Modifications:
As-Is
50%
Full Symmetry
G-Tube Cut Out
Adjustable Length Straps
Lordosis:
As-Is
15 deg
Other: ____________
Extended Buckles
Abdomen Relief:
None
XS
Shoulder Straps
Buckles Posterior
Build Breasts into Orthosis
S
L
M
Options:
XL
Draw in Abdominal Relief:
Cup Size
Side:
Left
Hip Spica Additions
Right
Joint Type:
Cuffs:
Detatched
Integrated -
Drop Lock
o
Flexion:
B3- ROM
A/P
M/L
o
Abduction:
Special Instructions or comments:
Draped Xyphoid to Pubis
MEASUREMENTS
Circ.
M/L
Measurements taken:
Standing
Supine
A/P
Sternal Notch
Axilla
Nipple Line
Nipple Line
Xyphoid
Xyphoid
Lower Rib
@ Xyphoid
Waist
ASIS
Waist
x
x
Trochanter
Symphysis Pubis
(for hip spica)
3" Distal to
Perineum
TLSO
Finished Measurements
Pubis
Xyphoid
Axilla
Sternal Notch
Inf. Angle Scap
Seat
Spine of Scap
Mid Scapula
LSO
3" Proximal to KC
Finished Heights
Standard Reduction
20 Ledin Dr., Avon, MA 02322 Phone : (800)262-2235 or (508) 588-6060 Fax: (800) 634-5048 or (508) 587-8119 www.bostonbrace.com