Orthometry Diagram
Measurement Instructions
Measurement Legend
A. Floor to Perineum (subtract 11/2” )
B. Floor to knee center
C. Floor to top of medial malleolus
D. Floor to trochanter (for hip joint)
E. Proximal thigh circumference - taken 11/2” from
Perineum
F. Distal thigh circumference - taken 2” above knee
G. Tibia circumference
H. Knee – medial-lateral
I. Pelvic circumference (for hip component)
J. Waist circumference (for hip component)
Left
Carefully measure your patient as indicated on the diagram. Be
sure to indicate your choice of components from previous page
in the column below. Call or fax your information once you
have completed the form. If you have any questions or need
additional measurement forms, please call our Customer Service
department.
Fill in selection of components from previous page
Hip component
Thigh component
Hip joint
Right
Tibia component
J
Foot component
Pelvic
Circumference
I
Knee joint
Shoe size
Perineum
D
Note: one stockinette included
E
A
Additional Stockinette
F
35
Quantity
Tibia
Femur
H
Knee
Center
Desire M-L
for Clearance
B
Company
G
Ship to address
Ant. Dist. Trim
Contact
C
Phone
Heel Base
Patient name
Height
Weight
Ship Date
Ship via
P.O.#