boston scoliosis measurement form

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BOSTON SCOLIOSIS MEASUREMENT FORM
Date:
Due Date:
Contact
Ship To:
Account:
E-mail
Address:
PO#:
Phone:
Ship Via:
Fax:
City:
State
Zip
PATIENT INFORMATION
BRACE DESIGN
Patient Name:
Age:
Sex:
Ht:
Wt:
Diagnosis:
Previous wearer?
Yes
No
For clinic use ONLY
Axilla:
Left
Right
None
Thoracic Extension:
Left
Right
None
Thoracic Window
Left
Right
None
Lumbar Pad:
Left
Right
None
Trochanter Extension:
Left
Right
None
Pad
@
@
Pad
ORTHOSIS INFORMATION
Finished?
Yes
Design:
Modifications:
No
(radiograph required for finished braces)
Measurement?
Abdomen Relief:
None
S
M
o
Abdominal Compression:
Scan Label:
Color/ transfer
Standard
L
Lordosis:
Gusset material on window
Material:
Transfer on gusset
Liner:
Transfer on straps
Additional Components
Milwaukee Style Measurements
Neck Ring:
Lumbar reinforcement
Left
Right
Special Instructions or comments:
Lumbar relief
Left
Right
Kyphosis Pad:
15 degrees lordosis,
white co-poly (thickness sized to model),
3/16" aliplast liner
10 degree abdominal compression
Waist to:
Chin:
Neck :
ML
Shoulder:
AP
Occiput:
Circ
MEASUREMENTS
Circ.
M/L
A/P
Axilla
Sternal Notch
Nipple Line
Xyphoid
Xyphoid
Lower Rib
@ Xyphoid
Waist
Waist
Finished Measurements
ASIS
x
x
Trochanter
Symphysis Pubis
Pubis
Xyphoid
Axilla
Sternal Notch
Inf. Angle Scap
Seat
Spine of Scap
Mid Scapula
Trim-lines @ BB discretion based on blueprint
Finished Heights
20 Ledin Dr., Avon, MA 02322 Phone : (800)262-2235 or (508) 588-6060 Fax: (800) 634-5048 or (508) 587-8119 www.bostonbrace.com