lY:Ieasuring~O.rm - Flat Knit Custom

lY:Ieasuring~O.rm
SunMED Medical
PH:800-714-7434
FX: 800-715-5423
- Flat Knit Custom
I feel better.
To process fax insurance information and this order to 800-715-5423
____________
_ _ _ _-----"P.O. #
Date
Account~
____________
Bill to:
Ship to:
Account Name
Patient Name
He ight
_ _ _ _ Weight
________l.LDi agn 0 s is
1
CIRCUMFERENCES
MATERIAL
em
T
o Below Knee 0 Thigh-High
o Pantyhose
o Thigh w/ waist attachment
o One-Leg Panty
o Bicycle Shorts (T to F)
o Capri Shorts (T to C)
o Leggings (T to B)
o Men's Waist w/Fly
o Maternity Panty (tricot panel)
LH
eK (around both legs)
H
~(L
l'
I
eCl III
I
em
LG
RIGHT
em
em
em
em
LF
em
(straight line)
REQUIRED FOR THIGH AND PANTY/WAIST 7
BACK
LK2
(gluteal fold to floor)
em
(straight line)
em
em
LE
em
em
reD
em
em
LD
em
em
CCLIV 2
t5
3
B
Pair
lnlt
Pair
LEFT
____cm
Left side
Right side
cA
em
eA
em
LAi
em
LAI
em
LA
em
LA
em
LZ
em
LZ
em
49-60~
Right Leg
Right _
J!j~
I LK2T
WEIGHT BEARING (must complete all) 8
C
Right _
RIGHT
em
(straight line)
em
LK1
(pubic bone to floor)
____cm
eE
Left Leg
Black
Left _
eG
I eC
QUANTITY/COLOR
I LK1T
F
Panty Section
Caramel
_ Left _
LEFT
eF
~ I :i l
eel II
(straight line)
G
550 only
18-2lmm/Hg 23-32rrvn/Hg 34-46rrvn/Hg
LT
em
I
STYLE
I
REQUIRED FOR THIGH AND PANTY/WAIST 6
"Y
IJi
Ideal for lymphedema
eeLi
5
cm
FRONT
o MONDI (CCL 2,3)
o 550 (CCL1,2,3,4)
COMPRESSION
LENGTHS
cm 4
I
I eB1
em
em
em
em
LC
LB1
em
em
em
em
lAi LZ
lA
FOOT
eB
em
em
eY
em
em
LB
em
em
9
o Open Toe
o Closed Toe
o Netting (no compression) (550 only)
o Tricot Standard (half compression)
Medi USA. 6481 Franz Warner Parkway. Whitsett, NC 27377 • Phone 1-800-633-6334
c.q
(\
c
a.
lft~mit~ \M'~a$urihg Form -Flat Knit Custom
SunMED Medical
PH:800-714-7434
FX: 800-715-5423
I feel better.
To process fax insurance information and this order to 800-715-5423
P.O. #
Date
Account #
Account Name
Patient Name
10
ADDED LENGTH
o Y Knitting mark at ankle = lcm
o Below Knee Stocking - 4cm added outside length
o Thigh Length Stocking (may choose both of
o E Knitting mark at knee = 4cm
LYMPHPADS - At: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
SILK LINING - At: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
following options)
(take straight line measurement from
floor to crease behind knee)
18
14
KNITTING MARKS/ANATOMICAL JOINT ANGLES
______,cm
(Provide sketch and dimensions in Notes area)
D Added length in front (must provide LKl and
LK2 measurements), Standard
D Added length on side SILICONE TOPBAND OPTIONS
Bcm
19
11
LEVAMED SILICONE ANKLE PADS (OPTIONAL) 15
o Profile (honeycomb pattern), 5cm
width only, Standard
o Beaded
Left Dinner
ZIPPER - At:
(Provide sketch and dimensions in Notes area)
Notes/Illustrations/Special Requests
D outer
D Small (2.5cm width)
D Wide (5cm width)
Right Dinner
o Peony (beaded with lace)
)
D outer
5cm width only
ADDITIONAL BEADED SILICONE OPTIONS
12
o Horizontal strip at "G"jside of thigh (5x15 cm)
o Vertical strip above knee (5xl0cm)
o Vertical strip below gluteal fold (5xl0 cm)
WAISTBAND OPTIONS
o Adjustable Waistband (Standard)
o Velcro Waistband
o Knitted Ending
o Silicone Beaded Waistband (5cm width only)
13
16
GENITAL LYMPHEDEMA
o Female
o Full Compression
o Half Compression - Standard
o Male - If selected, Pouch will replace open fly
o Full Compression
o Half Compression
o Non Compressive Netting
Pouch Circumfrence
Pouch Length
Open Crotch Pantyhose
o Female
o Male
(no open fly)
cm
cm
17
email pictures to customs@mediusa.com
20
Compression stockings with seams should not be measured until the best possible decongestion effort has been achieved. Circumference and
length measurements are taken in a distal to proximal sequence.
It is essential to mark the measuring points on the leg so that the circumference and length measurements are taken at the same point.
The amount of tension applied must be determined by a person experienced in bandaging techniques and depends on the edema and tissue
characteristics, sensitivity to pain, fibrosis , location of the edema, mobility and strength of the patient.
cA Measuring Options
Foot circumference (1)
Vl=slanted ending
V2=straight ending
a) Take cA measurement when patient
is weight-bearing
b) Measure circumference for either
slanted or straight endings
Leg circumference (2)
a) Relax leg when measuring
b) Mark the measuring points
Knee slightly flexed
c) For circumference cY, bring the foot
to the 90' position
d) Take the remaining circumference
measurements (except cE) up to cF
with the leg relaxed
e) For circumference measurement cE,
the knee must be slightly flexed
Leg length (3)
Foot positioned
at 90'
a) Relax leg when measuring
b) Hold foot in 90' position and take
each length measurement
Edge of heel
c) Always measure along the contour of
leg, preferably on medial aspect. If edema
is more pronounced on lateral (outside)
side , take measurements laterally
Foot length (4)
Measure medial, lateral and total lengths on weight-bearing foot as shown
tz
= Total foot length
tAi = From point of medial cA circumference to heel
tA = From point of lateral cA circumference to heel
Thigh topband (5)
a) In standing position, measure circumference cG 3 cm
below crotch or at widest part of upper thigh
b) Measure length tG in standing position from same
landmark still following the contour of the leg
r
Added thigh length (6)
a) Measure tKi in standing position from floor to pubic
bone (straight line)
b) Measure tK2in standing position, from floor to gluteal
fold (straight line)
Panty section circumference (7)
a) Measure circumference cH in standing position at the
widest part
b) Measure circumference cT in standing position at
waist or desired term ination point
c) Measure length t H in standing position at same
landmark as cH (straight line)
I
---- - '
Length of panty section (8)
a) Measure front of panty section tKiT
from crotch to height of cT circumference
measurement following the contours of
the body
b) Measure back panty section t K2T
from gluteal fold to height of cT
circumference measurement following
the contours of the body again