Patient Knee Brace Evaluation Form

PATIENT KNEE BRACE EVALUATION FORM

Patient Name______DOB______Male  Female 

Physician ______NPI No. ______General Patient Profile

Walks: Independently Uses CaneUses Walker Uses Wheel Chair Weight (lbs.) ______Height______

Dr. Rx Medical Necessity  VertaLoc Dynamic Knee Brace   VertaLoc Max OA Knee Brace 

To facilitate healing following a surgical procedure to the knee or related soft tissues. Date of procedure ______Description:______ To facilitate healing following an injury to the knee or related soft tissues. Description:______ To reduce pain by restricting mobility of the knee.

 To otherwise support instability of the knee.

Patient Measurement :

Dynamic Knee Brace - Around Knee – Measure around the Entire Knee: Inches = ______

Max OA Knee Brace – Around Thigh – Measure around the Entire Thigh: Inches = ______

(Order Brace size to match the appropriate measurement)

S M L XL 2XL 3XL US Diagnostics Knee Brace 14”- 17”- 20”- 23”- 26”- 28”- 17” 20” 23” 26” 28” 31” Dynamic Knee Brace

R or L 4-5XL S M L XL 2XL 3XL Knee 27”- US Diagnostics Knee Brace 15”- 17”- 19”- 21”- 23”- 25”- 30” 18” 20” 22” 24” 26” 28”

Max OA Knee Brace

Follow-up Patient Notes: ______

Fitter Name ______Date ______