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PROSTHETIC PATIENT ASSESSMENT FORM PATIENT INFORMATION Patient Name: Address: Phone Number(s): Personal Info: Birthday: Age: Height: Weight: AMPUTATION INFORMATION Amputation Location: Right side.

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  1. Select the orange Get Form button to begin editing and enhancing.
  2. Activate the Wizard mode on the top toolbar to have more tips.
  3. Fill in each fillable area.
  4. Make sure the details you add to the OptechO&P Prosthetic Patient Assessment Form is updated and accurate.
  5. Include the date to the template with the Date option.
  6. Select the Sign button and create a digital signature. Feel free to use three options; typing, drawing, or capturing one.
  7. Re-check every area has been filled in correctly.
  8. Select Done in the top right corne to export the sample. There are various choices for getting the doc. An attachment in an email or through the mail as a hard copy, as an instant download.

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  • prosthetics
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  • Orthotics
  • Circulatory
  • PROSTHETIC
  • Amputation
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