programs - amputee rehab center - amputee rehabilitation

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Planning a peer visit | Following the visit

The following information is strictly confidential and will not be communicated to anyone under any circumstances .It will be used only by the Peer Visitor Program to validate the usefulness of the visits and maintain contact with the amputees who are interested in being contacted.

* Name of the peer visitor :

* Date of the visit :

Information : name of the person visited and place of the visit

* Name

Address :(where visit is held)

* Phone number : (for the visit)

Other pertinent information

Age:

M F

Date of amputation :

Type of amputation

Lower limb

Upper limb

Right	Foot
Left	Under the knee
Bilateral	At the knee
N/A	Above the knee
	Hip disarticulation

Right	Hand
Left	Under the elbow
Bilateral	At the elbow
N/A	Above the elbow
	Shoulder

Cause of amputation

Diabetes

Cancer

Vascular

Trauma

Congenital

Other:

Additional comments, suggestions and feedback

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