1. I'
Multinational Life Insurance
Company
- cSeguro te !ResponcCe-
GAil Jj)fE~Cm~TI(jlN
SSN: ~~-93- Vy?
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1. ts the g~it: DNorm~1 DAnt~lgic? DProtecting one I~g: ORt
Olt leg
OWith el rigid
spine?
2. Does the patient DUmp? F~voril1g: DIRt OLt leg Delmg a leg due to
weakness? 0 Rt Ou leg
Djust keep the leg rigid but bears weight IOn it? commems; ____ _
3. Strength Ell lower eY.tremiti~: Right:, _____________Left
. ls mere atrophy present? DYes ONo. Location and.
measurements:
--------------------~--------------------------------
4. Are any of these findings present which alter gait? DAtaxia
Dlack of balance 0 lack of coordination: ORt DLt leg
Comments: _________________________________________________--:..._--------- -
5. Does the patient use: DCane: DRt OLt hand 0 Orthopedic shoes 0 Shoe lift DCrutches
DWheelcl1air DAFO (asslstive foot orthotic): DRt Dlt foot DProsthetic
limbs ORt Du leg
Comments:. _________________-:- ___________________________________ _
6. Did you examine patient's gait without asslsnve device? DYes ONe ON/A
7. Did you examine patient's gait Vl,tith prosthesis in place? DYes ONo ON/A
8. Did a physician prescribe assistlve device or prosthesis? DNo Dyes. If so, please indicate
physician's name:
---
9. Describ~ gait while using ormopedic shoes or lift: DNormal OAbnormal. Explain: _
10. Describe gait usirlg prosthetic limb. UNormalDAb normal. Explain: _
9. Any problem at stump area? ONe Dyes. Explain:, ___________________________________________
-..,.. _
10. Is the cane considered necessary all the time and in all types of terrain? DNo Dyes. Why? ________
_
11. Does the patient use the walls or require someone's assistence for support? DNa DYes. if
support is necessaN
does it mean that he/she needs some kind Qf asslstlve device? ONo DYes. Explain: < ,
DSpasticity
Dll1voJuntary movements
DUnstable joint DRigid tone DFlaccid tone.

2. Offic-e dayslhou!"s: Mon _____________Tue. _____________Vfed. ____________Thu ___________Fri. _________
Sat:
._----
Physician's
Signature
Physician's Name (Please
print)
D
a
t
e
I
elephone/
Fax
Avenida Munoz Rivera 510, San Juan, Puerto Rico 00918 e PO Box 366107 San Juan, PR 00936-6107 " Tel.
787-758-8080