Patient Assessment Form — Nabdh Al-Taqnia

Nabdh Al-Taqnia

نبض التقنية

Patient Assessment Form

Prosthetics · Orthotics · Medical Aids · Rehabilitation

Record No. PO-2026-0001

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Personal Information 01

Full Name *

A record with this name already exists.

Date of Birth *

Age

National ID

Gender *

Male Female

Patient
Photo

Phone *

Emergency Contact

Address

Referral & Medical Background 02

Admission Date *

Referred By

Referring Physician

Primary Diagnosis *

Drug Allergies

Current Medications

Past Medical History

Diabetes mellitus Hypertension Cardiovascular disease Peripheral neuropathy Renal failure Osteoporosis Stroke / TBI Spinal cord injury Oncology / Cancer Mental health condition Previous surgery Other

Cause of Condition 03

Trauma & Injury

War / blast injury IED / landmine Road traffic accident Motorcycle accident Work / industrial accident Fall from height Crush injury Gunshot wound Electrical injury Burns

Incident details

Medical / Disease

Diabetes mellitus Peripheral arterial disease Diabetic foot / gangrene Severe infection / sepsis Osteomyelitis Chronic venous insufficiency Frostbite Renal failure complication

Neurological

Stroke / CVA hemiplegia Spinal cord injury Traumatic brain injury Peripheral nerve injury Cerebral palsy Poliomyelitis Multiple sclerosis Muscular dystrophy

Congenital / Genetic

Congenital limb deficiency Clubfoot / talipes Spina bifida Arthrogryposis Achondroplasia Hemimelia / phocomelia Osteogenesis imperfecta Other congenital

Oncology / Tumor

Bone tumor resection Soft tissue sarcoma Osteosarcoma Post-radiation necrosis Metastatic bone disease Other tumor-related

Tumor type / stage

Musculoskeletal

Osteoarthritis Rheumatoid arthritis Scoliosis / kyphosis Fracture complication Joint instability Ligament / tendon rupture Osteoporosis Failed joint replacement

Duration since onset

Previous treatment

Selected causes:

No causes selected yet

Amputation / Deficiency Assessment 04

Complete for amputee patients only. Skip if non-amputee.

Amputation Level

Side Affected

Time Since Amputation

Residual Limb Shape

Skin / Wound Condition

Residual limb measurements (cm)

Stump length

Proximal circumference

Mid circumference

Distal circumference

Contralateral limb length

Phantom limb pain / sensation

None Mild Moderate Severe

Prosthetic & Orthotic Device 05

Service Type *

Device Category *

Socket / Interface Type

Suspension System

Activity Level (K-Level)

Patient Goals & Expectations

Functional & Rehabilitation Assessment 06

Current Mobility Status

Rehabilitation Priority Moderate (5)

Low Urgent

Associated Impairments

Muscle weakness Contracture / joint stiffness Spasticity Sensory loss Balance impairment Pain (residual / phantom) Pressure ulcers Cognitive / speech issues Visual impairment Incontinence

Clinical Notes / Therapist Observations

Administrative & Funding 07

Funding Source

Case Priority

Assigned Clinician

Next Appointment

Estimated Delivery / Fitting Date

Patient data is confidential — authorized personnel only

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