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ID#
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Post Mastectomy
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Affected Side
• • •
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Wound Present
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Currently Wearing
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Previous Bandage/Garment Use
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Touch Sensitivity
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Skin
• • •
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Reason for Compression
• • •
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Compression Level
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Left Ankle Measurement
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Right Ankle Measurement:
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Left Calf Measurement:
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Right Calf Measurement
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Right Thigh Measurement
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Left Thigh Measurement:
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Length
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Wrist
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Elbow
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Axilla
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Length
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Palm
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Items to be ordered
• • •
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Open or Closed Toe
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Color:
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Silicone Border?
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MANUFACTURER / STYLE / COMPRESSION
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Night Garment
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Pump
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Other Item Requested:
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Manufacturer of Item Received
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Style
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Size
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Color
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Quantity
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Manufacturer of Item Received
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Style
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Size
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Color
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Quantity:
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Care/ Wear Instructions Given
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NOTES
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Fitted by:
• • •
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Proof of Delivery
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Custom Arm - Juzo
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Custom Leg - Juzo
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Custom Hand - Juzo
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Juzo Leg Chart
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Arm Sleeve / Gauntlet Sizing
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Thigh, Calf, Foot- Circiad Reduction
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