Integral Leg Patient Information Form:

First Name:

Last Name:

Address:

City/Suburb:

State:

Postcode:

Country:

Date of Birth:

(dd/mm/yyyy)

Email Address:

Phone Number (Please include area code):

Message:

How did you find out about Osseointegration?

Please assist us with your enquiry by providing the following information.
This is the first step as we have a very strict selection criteria.

Please note that the questions are in order of importance.

History of diabetes:

Yes No

History of smoking:

Yes No

History of peripheral vascular disease

Yes No

History of psychological disease (minor depression is not included):

Yes No

Cause of amputation:

Site/level of amputation:

Time since amputation:

Age:

Years

Body Weight:

Kgs

Height:

cms

Marital Status:

Children:

Employment:

Level of activity:

Allergies:

Current type of prosthesis (if applicable)

Current prosthesist name (if applicable)

Current prosthesist address (if applicable)

Name of GP

Address of GP

Phone Number of GP

Current medication (if applicable)

Previous surgery (if applicable)

Comments: