AMPUTEE MOBILITY PREDICTOR ASSESSMENT TOOL FOR PATIENTS ABILITY OR POTENTIAL TO USE PROSTHESIS

Initial instructions: Client is seated in a hard chair with arms. The following manoeuvres are tested with or without the use of the prosthesis. Advise the person of each task or group of tasks prior to performance. Please avoid unnecessary chatter throughout the test. Safety First, no task should be performed if either the tester or client is uncertain of a safe outcome.

Question Title

* 1. Name and/or ID

Question Title

* 2. DOB

DOB

Date

Question Title

* 3. Assessor

Question Title

* 4. Date and Time

Date / Time

Date

Question Title

* 5. The Right Limb is:

PF (partial foot)

TT (transtibial)

KD (knee disarticulation)

TF (transfemoral)

HD (hip disarticulation)

intact

Question Title

* 6. The Left Limb is:

PF (partial foot)

TT (transtibial)

KD (knee disarticulation)

TF (transfemoral)

HD (hip disarticulation)

intact

AMPUTEE MOBILITY PREDICTOR ASSESSMENT TOOL FOR PATIENTS ABILITY OR POTENTIAL TO USE PROSTHESIS

Question Title

* 1. Name and/or ID

Question Title

* 2. DOB

Question Title

* 3. Assessor

Question Title

* 4. Date and Time

Question Title

* 5. The Right Limb is:

Question Title

* 6. The Left Limb is:

Question Title

* 7. Score

Question Title

* 8. Associated K Level