Prosthetic Socket Assessment Form
Prosthetic Socket Assessment Form for evaluating socket fit and related wear issues.
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Clinician Name
*
Limb Side
*
Left
Right
Bilateral
Type of Prosthesis
*
Please Select
Transtibial
Transfemoral
Upper Limb
Other
Primary Fit Concern
*
Too Loose
Too Tight
Pressure Points
Alignment Issue
No Major Issue
Pain/Discomfort Severity
*
None
0
1
2
3
4
5
6
7
8
9
Severe
10
0 is None, 10 is Severe
Skin Condition at Socket Interface
*
Normal
Redness
Blistering
Open Wound
Other
Socket Comfort Rating
*
1
2
3
4
5
Satisfaction with Prosthetic Socket
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
The socket fits comfortably
1
2
3
4
5
The socket is stable during movement
6
7
8
9
10
The socket is easy to don and doff
11
12
13
14
15
Overall satisfaction
16
17
18
19
20
Clinician Notes
Submit Assessment
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