* * * " LYMPHEDEMA FACEMASK / OPEN FM CHINSTRAP COLLAR/HEADBAND. Name: Date: Therapist: Clinic: Weight: M / F Adult / Child
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1 FACEMASK / OPEN FM CHINSTRAP COLLAR/HEADBAND : Fit Well / Loose / Tight Style: Same Style as prev. / New Style! FROM EAR TO EAR PLEASE NOTE: Essential measures shown with a " " SEPARATE COLLAR / HEADBAND Reg / Soft Collar Width: 2" / 3" Elastic: 2 Lining: Standard FACEMASK / OPEN FACEMASK / CHIN STRAP Reg / Soft Lining: Front / Back Other Lining: Soft / Silicone Location: See separate chart Closure: Velcro / Zip Ears: Open / Closed Pressure: (20-30 mm) (30-40mm) Does the patient have long hair?!! DOWN MEASUREMENTS GIRTHS AROUND HEAD MK / SD / 1WSOFT / 2WSOFT FM/CH Lining: Front / Back / 2WSOFT Headband Type: Fabric / Elastic Closure Lining: Elastic 1" / 2" 1WSOFT / 2WSOFT Velfoam: 2" Fabric Triangle HB Velcro Back: 1 1/2" x 2 1/2" HB Lining: 2WSOFT Velform padding: Inbetween dn
2 : Fit Well / Loose / Tight Len.: Fit Well / Short / Long Style: Same style as prev. / New Style Glove with attached 1/2 sleeve: 0 wrist 1 3/4" 16 Heintzman Street GLOVE CHART Closed / Open / Gauntlet Line up middle finger with vertical line above Fabric Color: Thread Color: ZIP Placement: ZIP Lining: Other Lining: Location: Reg / Soft Beige / Black / Pink / Blue Beige / Black / Pink / Blue Dorsal / Palmar Elastic / Fabric Soft / Silicone See separate chart Taper Fingers: Yes / No Burned Thumb Web: Yes / No Emblems: Pressure: (20-30mm) (30-40mm) Graduated 2 Please write darkly, clearly and large. Zip Lining: 1", 1" / 2" Elastic Thumb: Single Soft / Double Soft Short Fingers - Soft Gussets 1/2 Pressure at Overlap %: None dn
3 SLEEVE CHART : Fit Well / Loose / Tight Style: Same style as prev. / New style PLEASE NOTE: Draw burns on burn assessment chart. Sleeves and gloves must overlap 2. Sleeves should anchor proximal or distal to muscle, NOT mid muscle. SHOULDER POINT Right s Left Reg / Soft ZIPS Placement: Radial Center Dorsal: L / R ZIP Lining: Elastic / Fabric Elbow Lining: Single Soft / Double Soft Other Lining: Soft/Silicone Location:See sep. chart Graduated Pressure: Yes / No Pressure: (20-30mm) (30-40mm) Attach 1/2 sleeve to glove/ gauntlet: Yes / No Sleeves Attached To Vest: Yes / No Ulnar A.P. ELBOW CARPAL JOINT Zip Lining: Elastic / Fabric(1wsoft) 1", 2" 1/2 Pressure at Overlap %: None Nv RH
4 16 Heintzman Street VEST CHART Sleeve: None Half Full : Fit Well / Loose / Tight Where: By How Much (est): Where: By How Much (est): Style: Same style as prev. / New style Regular / Soft Neckline: 1/2 (standard) / 1 / 2 Lined Opening location: FR / BK Both Opening Type: Velcro / Zip Bra Cup: YES NO Bra Size: Low neck: Pressure: (20-30mm) (30-40mm) Other Lining: Soft / Silicone Location: See separate chart Baby Anchor / : Circumferences SH Right Arm Pit AP: FRONT s N N Left SH Shoulder pt. to Shoulder pt. Left BACK Shoulder pt. to Shoulder pt. Right Nipples: Rib Cage: Neck Circumferences Top: Bottom: Mid: Axilla Circumferences Female Waist: Navel: Right FRONT Left Male Waist: Hip: (Final length includes elastic) To Note: Please draw burns on burn assessment chart. - One shoulder higher than the other (note R. or L.) - Mark concave areas - Posture Closure: Velcro / ZIP Zip:vest:RG/ LG Att Sleeve-RG / SJ Lg / Sm Clos. Lining: Elastic/Fabric1 / 1.5 Bra Type: Regular / "S" Curve / Moulded Bra Lining: 2WSOFT Neckline- Fabric-MK- 1' / 2" / 2 1/2" Lined Pressure: Graduated 1/2 Pressure at overlap %: None Oct--13-RH -
5 LEG CHART Circum: Fit Well / Loose / Tight By How Much (est): By How Much (est): Style: Same Style as prev. / New Style PLEASE NOTE: All lengths include elastic Legs and socks must overlap 3 1/2 Reg / Soft Crotch Style: Open / Closed 1/2 Open Crotch (closed in back, open in front) Zips Placement: Anterior: L / R Zip Type: RG / SJ LG / SM Zip Lining: Elastic / Fabric Knee Lining: Single Soft / Double Soft R L Other Lining: Soft / Silicone Location: See separate chart Pressure: (20-30mm) (30-40mm) Medial Centre Lateral Ankle Bone to Navel Female Waist Navel Male Waist Hips Crotch (AB touching) RIGHT LEG (From Navel) (From Navel) Total (Navel to ankle bone) = Same Crotch LEFT LEG (From Navel) KNEE Below Knee Zip Lining: Elastic / Fabric (1wsoft) 1", 2" Angled Waist Pressure: Graduated 1/2 Pressure at overlap %: None Largest Calf Protrusion Above Ankle Bone NOTE: For full leg end 1" proximal to the ankle bone. No-11.2dn
6 SOCK CHART : Fit Well / Loose / Tight Style: Same style as prev. / New style PLEASE NOTE: Socks and legs must overlap 3. Ankle socks should begin at least 3 above ankle bone. Right s Left Reg / Soft ZIPS Placement: Medial Centre ZIP Lining: Elastic / Fabric Soft Lining: Crease / Ankle Back / Heel: Other Lining: Soft / Silicone Location: See sep. chart Style: Open / Closed Trace foot for closed sock & footglove. Footglove: YES / NO Pressure (20-30mm) (30-40mm) Graduated Anterior: L / R Lateral For length only Closed Sock ANKLE BONE HEEL INSTEP For length only Open Sock No Zip Lining: Elastic / Fabric(1wsoft) 1", 2" PRESSURE: 1/2 Pressure at overlap %: None Nov -11
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