KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLITEKNIK KESEHATAN SURAKARTA

JURUSAN ORTOTIK PROSTETIK

Jl. Kapt. Adi Sumarmo, Tohudan, Colomadu, Karanganyar, Surakarta

Telp.0271-726223 Website : www.ortotikprostetiksolo.com

PATIENT MEASUREMENT CHART

TRANSTIBIAL PROSTHESIS
Date : ...........................................................
Student Name : ………………………………………………
NIM : ………………………………………………
Class/Semester : ………………………………………………
Year : ……………………………………………....

1. Patient Name :
2. Place, Date of Birth :
3. Age :
4. Height/Weight :
5. Gender : M/F
6. Addres :

7. Contact/Phone :
8. Occupation :
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