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5.2 Measurement form
Measurement Form for Polyurethane (PUR) Liner
Transtibial and Syme amputations
Contact
Customer
Company
Street
Postal code/city
Email
Patient ID
PUR custom liner from plaster cast and
6Y400
measurement form
6Y400=M
PUR custom liner from measurement form
Shape Plus PUR custom liner from
6Y416
plaster cast and measurement form
f I
h t
e
p
a l
t s
r e
c
a
t s
h
s a
c
o
m
l p
a bulging, eccentric or concave residual limb end, pronounced
invaginated scar tissue or excess size (length > 50 cm, circumference
> 50.5 cm), a 6Y416 Shape Plus Liner is required.
R
e
p
a l
c
e
m
e
t n
c
u
s
o t
m
please contact customer service.
W
a
t l l
i h
k c
n
e
s s
o t
e l
a r
n
c
s e
f o
O
t
o t
b
o
k c
t s
r o
s e
h t
e
p
a l
t s
r e
most recent order.
Wall thickness
U
n
f i
r o
m
(with 13 mm distal cushion)
(Wall thickness:
4 mm
(6 mm wall thickness at knee centre tapering to
T
a
p
e
e r
d
Width of the distal residual limb end
(if deviating from 13 mm)
Distal connector
W
i
h t
o
t u
(requires the selection of a textile coating)
W
i
h t
Comments:
Otto Bock HealthCare GmbH · Max-Näder-Str. 15 · 37115 Duderstadt
T +49 5527 848-3030 · F +49 5527 848-1585 · servicefertigung@ottobock.de · www.ottobock.com
Harmony System
Right
x e
e f
t a
r u
s e
s
u
c
h
s a
k
nee flexion > 15°,
l
n i
e
: r
±
1
0
%
a
e r
p
o
s s
b i
e l
o
n
subsequent orders.
c
a
t s
d
a
a t
s a
a
f
e l i
o f
r two years after the
5 mm
6 mm)
mm
Customer
number
Shipping address
Company
Street
Postal code/city
Phone
Exterior coating
W
i
h t
e t
x
i t
e l
1.6 mm, colour:
0.6 mm, colour:
1.0 mm, colour: Silver
Without textile coating (requires a non-adhesive coating)
S
K
I
N
G
U
A
R
Lower leg measurements
Extend the measurement sections if necessary.
Residual
limb length
mm
Date
c
o
t a
n i
g
Skin colour
Skin colour
D
T
E
C
H
N
O
L
O
G
Y
+ 100 mm
+
50 mm
MPT
+
50 mm
+ 100 mm
+ 150 mm
+ 200 mm
+ 250 mm
Minimum
circumference
Maximum
circumference
Appendix
or
Black
or
Black
mm
mm
Ottobock | 31
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