Transcription of Wrist-Hand Orthosis - SPIO
1 Wrist-Hand Orthosis Custom Measurement FormPlease include a copy of the SPIO Order Form along with your custom measurement should be in centimeters. All boxes must be filled in. Length = Circumference = Measurement KeyColor o BLACK o ROYAL BLUE o WHITEL ayers o SINGLE o DOUBLEO ptionsAdditional Comments_____cm_____cmWrist (at crease)to MCPW rist (at crease)to Palm (at web-space)_____cmMCP_____cmWrist (at crease)_____cmThumb IP_____cmThumb MCP_____cmGlove End_____cmMCP to IP( Thumb)_____cmGlove Endstandard 5-7cm)Date _____Name (Patient) _____ Age _____ Contact Name _____Contact Phone _____ Contact Email _____Line A - CLine B - CLine C - DLine E - FABCDEF
