Date of filling in

1) Personal data:

Residence address:

2) Amputation data:

Age:

Amputation side: RightLeft

Date of amputation:

Amputation level: ShinThighForearmArm

Cause of amputation: InjuryVascularOncologicalOther

Healing process: NormalWith complications

Course of treatment (brief description, hospital and duration of stay in hospital):

3) Current condition of the stump (short description):

4) Prosthesis:

Information
Please send us the following, before a medical consultation:

• Filled in questionnaire;

• Photo of the stump (showing the shape of the stump);

• X-ray of the stump with a ball;

• CT of the stump along with the remaining limb.

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Accepted types of files: jpeg, jpg, bmp, png, tiff, jpe, jif, pdf, doc, docx, xdoc, zip, rar.
Max file weight: 5MB

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