Form 5 Lymphoedemas / Tailor-made
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1 Form 5 LC-500 Gauntlet with thumb LC Elbow-length gauntlet with thumb I II In case of gauntlet with full sleeve, please mark your preference: Hand Please add to Form 5 the corresponding form for the full sleeve. 7-A 7-B 7-C 7-D Measurements should be taken first thing in the morning. Measurements should be taken with a metric tape-measure taking care to complete them all. F5 - ENG Revisión: 1 Fecha: 01/10/2009
2 Form 6-A LC-501 Glove with fingers to the nail LC Elbow-length glove with fingers to the nail I II In case of glove with full sleeve, please mark your preference: Hand Please add to Form 6-A the corresponding form for the full sleeve. 7-A 7-B 7-C 7-D Measurements should be taken first thing in the morning. Measurements should be taken with a metric tape-measure taking care to complete them all. F6A - ENG Revisión: 1 Fecha: 01/10/2009
3 Form 6-B LC-502 Glove with fingers to the knuckle LC Elbow-length glove with fingers to the knuckle I II In case of glove with full sleeve, please mark your preference: Hand Please add to Form 6-B the corresponding form for the full sleeve. 7-A 7-B 7-C 7-D Measurements should be taken first thing in the morning. Measurements should be taken with a metric tape-measure taking care to complete them all. F6B - ENG Revisión: 1 Fecha: 01/10/2009
4 Form 7-A LC-503 Sleeve with stay-up silicon strip LC Sleeve with stay-up silicon strip, with gauntlet LC Sleeve with stay-up silicon strip and glove with short fingers LC-503.2L Sleeve with stay-up silicon strip and glove with long fingers I II In case of glove or gauntlet with sleeve, please mark your preference: Arm Please add to Form 7-A the corresponding form for the glove or gauntlet. 5 6-A 6-B Measurements should be taken first thing in the morning. Measurements should be taken with a metric tape-measure taking care to complete them all. F7A - ENG Revisión: 1 Fecha: 01/10/2009
5 Form 7-B LC-504 Sleeve with shoulder and narrow supporting strap LC Sleeve with shoulder and narrow supporting strap, with gauntlet LC Sleeve with shoulder and narrow supporting strap and glove with short fingers LC-504.2L Sleeve with shoulder and narrow supporting strap and glove with long fingers I II In case of glove or gauntlet with sleeve, please mark your preference: Arm Please add to Form 7-B the corresponding form for the glove or gauntlet. 5 6-A 6-B Measurements should be taken first thing in the morning. Measurements should be taken with a metric tape-measure taking care to complete them all. F7B - ENG Revisión: 1 Fecha: 01/10/2009
6 Form 7-C LC-505 Sleeve with shoulder and wide supporting strap LC Sleeve with shoulder and wide supporting strap, with gauntlet LC Sleeve with shoulder and wide supporting strap and glove with short fingers LC-505.2L Sleeve with shoulder and wide supporting strap and glove with long fingers I II In case of glove or gauntlet with sleeve, please mark your preference: Arm Please add to Form 7-C the corresponding form for the glove or gauntlet. 5 6-A 6-B Measurements should be taken first thing in the morning. Measurements should be taken with a metric tape-measure taking care to complete them all. F7C - ENG Revisión: 1 Fecha: 01/10/2009
7 Form 7-D LC-506 Sleeve with shoulder attached to bra strap LC Sleeve with shoulder attached to bra strap, with gauntlet LC Sleeve with shoulder attached to bra strap and glove with short fingers LC-506.2L Sleeve with shoulder attached to bra strap and glove with long fingers I II In case of glove or gauntlet with sleeve, please mark your preference: Arm Please add to Form 7-D the corresponding form for the glove or gauntlet. 5 6-A 6-B Measurements should be taken first thing in the morning. Measurements should be taken with a metric tape-measure taking care to complete them all. F7D - ENG Revisión: 1 Fecha: 01/10/2009
8 Form 8 LC-508 Below-knee stocking LC-509 One-leg stocking with hip support LC-510 Full trousers LC-510-E Full trousers of two separate stockings LC-513 Thigh-length stocking I II III Crotch Toe Open open closed Closed open closed Measurements should be taken first thing in the morning. Measurements should be taken with a metric tape-measure taking care to complete them all. F8 - ENG Revisión: 2 Fecha: 01/01/2011
9 Form 9 LC-507 Foot glove LC Foot glove with heel fastening I II Foot Measurements should be taken first thing in the morning. Measurements should be taken with a metric tape-measure taking care to complete them all. F9 - ENG Revisión: 1 Fecha: 01/10/2009
10 Form 11 LC-511 Bra Beige White Black LC-512 Bra-vest Beige White Black Inside prosthesis pocket I Neck V-neck Round neck II III Chest With neither breast Without right breast Without left breast Size Indicate your bra and cup size Size... Cup A B C D NOTE Model LC-512 can be made to the length needed. Measurements should be taken first thing in the morning. Measurements should be taken with a metric tape-measure taking care to complete them all. F11 - ENG Revisión: 1 Fecha: 01/10/2009
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