<p> PATIENT KNEE BRACE EVALUATION FORM </p><p>Patient Name______DOB______Male  Female  </p><p>Physician ______NPI No. ______General Patient Profile </p><p>Walks: Independently Uses CaneUses Walker Uses Wheel Chair Weight (lbs.) ______Height______</p><p>Dr. Rx Medical Necessity  VertaLoc Dynamic Knee Brace   VertaLoc Max OA Knee Brace  </p><p>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.</p><p> To otherwise support instability of the knee.</p><p>Patient Measurement : </p><p>Dynamic Knee Brace - Around Knee – Measure around the Entire Knee: Inches = ______</p><p>Max OA Knee Brace – Around Thigh – Measure around the Entire Thigh: Inches = ______</p><p>(Order Brace size to match the appropriate measurement)</p><p>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</p><p>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”</p><p>Max OA Knee Brace</p><p>Max OA Knee Brace</p><p>Follow-up Patient Notes: ______</p><p>Fitter Name ______Date ______</p>