Amputee Rehabilitation Intake Form
Personal Information
Full Name
Date of Birth
Gender
Contact Number
Address
Medical Information
Diagnosis
Date of Amputation
Level of Amputation
Side
Cause of Amputation
Other Medical Conditions / Comorbidities
Prosthetic History
Previous Prosthesis Used
Current Prosthesis
Issues With Prosthesis
Functional Status
Current Mobility Status
Ability to Perform Activities of Daily Living
Patient Goals