Prosthetic Maintenance Log
Please complete this form to record all maintenance activities performed on prosthetic devices.
Date of Maintenance
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Full Name
*
First Name
Last Name
Patient ID or Reference Number
*
Device Serial Number
*
Type of Prosthetic Device
*
Please Select
Lower Limb Prosthesis
Upper Limb Prosthesis
Partial Foot Prosthesis
Other
Type of Maintenance Performed
*
Routine Inspection
Cleaning
Adjustment
Repair
Part Replacement
Other
Description of Maintenance Performed
*
Parts Replaced (if any)
Device Condition Before Maintenance
*
Please Select
Excellent
Good
Fair
Poor
Device Condition After Maintenance
*
Please Select
Excellent
Good
Fair
Poor
Technician Name
*
First Name
Last Name
Next Scheduled Maintenance Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Comments or Observations
Technician Signature
*
Submit Log
Submit Log
Should be Empty: