1. No category

Page 1 of 3
(required)
Prosthetic Feet (selection) · General Patient Data
Fax to the addresses of our branches throughout
the world, which are listed at the end of this catalog.
Billing Address
Shipping Address (if different than billing address)
Customer no.
Customer no.
Company
Company
Address
Address
Orthopedic technician
Com.
Patient Data
Patient Mobility Grade
Mobility Grade 3
Name ____________________________________________
Moderate activity and low impact load. Everyday
activities such as walking and going up and down
stairs.
Moderate activity and moderate impact load.
Everyday activities, fast walking even on uneven
ground. Recreational activities such as hiking,
golfing, etc.
Age ______________________________________________
Sex
male
female
Weight _________________________________________kg
Size ___________________________________________ cm
Foot size _______________________________________ cm
Heel height _____________________________________ cm
Amputation side
left
right
Bilateral amputation
yes
no
Mobility Grade 4
Moderate activity and high impact load. Diverse
activities, above-average impact load and
mechanical demands on the prosthesis.
High activity and high impact load. Recreational
activities such as skiing, sprinting, weight training etc.
Previous foot (model) _______________________________
Stiffness/Flexibility
stiff
medium
soft
Amputation height (optional information)
Symes/Chopart
Transtibial
Knee disarticulation
Transfemoral
Hip disarticulation
Knee _____________________________________________
(a) Clearance: Socket end to floor _________________mm (a) Clearance:
End of knee to floor ___________________________mm
OR
OR
(b) MPT to floor (retained extremity) ________________mm
(b) MPT to floor (sound side) ______________________mm
(c) MPT to socket end ___________________________mm
(c) Knee center to end of knee_____________________mm
Clearance: (b-c) ________________________________mm
Clearance: (b-c) _____________________________mm
Other __________________________________________
Date _____________
Place _____________________________
Signature ___________________________________
Otto Bock HealthCare GmbH | Prosthetics – Lower Extremities | www.ottobock.com
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Pylon Foot System
Axtion® DP
Advantage DP2
1E58 (13 mm heel height)
System height: A-, B-Pylon max. 368 mm
1E50 (9 mm heel height)
Standard Pylon System height: A-, B-Pylon max. 370 mm
Long Pylon System height: A-, B-Pylon max. 498 mm
1E51 (19 mm heel height)
Springlite® II
Standard Pylon System height: A-, B-Pylon max. 362 mm
1E61 (13 mm heel height)
Long Pylon System height: A-, B-Pylon max. 489 mm
Standard Pylon
System height: A-, B-, C-Pylon max. 368 mm
Long Pylon System height: A-, B-, C-Pylon max. 495 mm
A-Pylon
Possible Adapters for:
Axtion® DP
Advantage DP2
Springlite® II
Pyramid Adapter/
Pyramid Receiver
Tube Connection
Socket Adapter
4R82=P
2R182=30
4R431=1
4R82
2R183
4R431=2
2R183
4R415
B-Pylon
2R183=L
Tube Connection
Socket Adapter
2R185=30
4R432=1
2R185=34
4R432=2
4R415
Springlite® II Pediatric
Possible Adapters for Springlite® II Pediatric
A-Pylon
1E66 (6 mm heel height)
System height: max. 375 mm
Pyramid Adapter/
Pyramid Receiver
Tube Connection
Socket Adapter
4R82=P
2R182=22
4R431=1
4R82
2R182=30
4R431=2
2R183
2R183
4R415
2R183=L
Scope for delivery:
Footshells
Axtion® DP:
A tool for removing the footshell, a Spectra-Sock and Crepe soles
are included in delivery.
for Axtion® DP, Advantage DP2, Springlite® II
Quantity Order no.
Sizes
/
2C5=
Side
Size
22-31 cm
Color
Colors
4
15
beige light brown
Advantage DP2, Springlite® II; Springlite® II Pediatric:
A Spectra-Sock and Crepe soles are included in delivery.
for Springlite® II Pediatric
Quantity Order no.
Sizes
2E3=
13 – 21 cm
Side
Size
2C100 Tool for Removing the footshell
Date _____________
282
Place _____________________________
Signature ___________________________________
Otto Bock HealthCare GmbH | Prosthetics – Lower Extremities | www.ottobock.com
Page 3 of 3
Modular Foot System
Chopart Plate
Axtion®
A spectra-sock and crepe soles are included in delivery.
Min. clearance: 17-24 mm
Crepe soles are included in delivery.
Please indicate the footshell and the glue set in the selection
below (footshell, fill foam).
Please indicate the footshell in the selection below
(footshell).
1E56 Axtion® with 13 mm heel height
1E80 Chopart with 0 mm heel height
firm
1E81 Chopart with 9 mm heel height
medium
soft
(Standard heel firmness is medium.)
1E82 Chopart with 19 mm heel height
Chopart Plate Pediatric
SL Profile Pediatric
Minimal clearance: 17 mm
Crepe soles are included in delivery.
A spectra-sock and crepe soles are included in delivery.
Please indicate the footshell in the selection below
(footshell).
1E87 Chopart with 6 mm heel height
1E79 SL Profile with 6 mm heel height
Lo Rider
A spectra-sock and crepe soles are included in delivery.
Please indicate the footshell in the selection below
(footshell).
1E57 Lo Rider with 9 mm heel height
Alternative adapter
XO Coupler for Lo Rider
SL=LR-XOCS-M6
(diameter 73 mm)
SL=LR-XOCL-M6
SL=LR-XOCL-5/16
(diameter 85 mm*)
* Delivered version depends on Mobility Grade and body weight.
Footshells
SL=P078 Chopart Bonding Kit
for Chopart, Lo Rider (sizes 24 – 31 cm), Axtion®
SL=PO71 Footshell Foam Kit (optional)
Quantity
Order no.
Sizes
/
2C5=
Side
Size
Colors
22-31 cm
Color
4
beige
2C100 Removal Tool (steel)
15
light brown
SL=Spectra-Sock Protective Sock
for Lo Rider (sizes 22 – 23 cm)
Quantity
Order no.
Sizes
SL=M
Size
Side
Size
Side
SL=F
23 cm
for men
22 – 23 cm
for women
for Chopart Plate Pediatric
Quantity
Order no.
Sizes
2E3=
13 – 21 cm
Side
Date _____________
Size
Place _____________________________
Signature ___________________________________
Otto Bock HealthCare GmbH | Prosthetics – Lower Extremities | www.ottobock.com
283