Instructions
If we have already received your unaffected measurements by fax, mail, email, or via this webpage, then only provide unaffected measurements if they have changed from the last submission. Enter the resulting measurements into the corresponding boxes in the chart. Here are a few things to be aware of about measuring:
- Make sure the measuring tape is snug, but not tight.
- Make sure when measuring, the tape is perpendicular with the limb, not at an angle.
- If bilateral, use unaffected columns for left limb and affected columns for right limb.     (Marked left and right in chart below)
- For measurements on the right side of the chart:
    - Measure the largest part of the thigh.
    - Measure the center of the knee cap.
    - Measure the largest part of the calf.
    - Measure the smallest part of the ankle.

Date:
Name:
Email:
Gauge:  Yes  No
Pressure set at  mmHg (if applicable)
Limb Affected:  Left  Right  Bilateral
Measured In:  Centimeters  Inches

UnAffected
(Left)
Affected
(Right)
Inches
from Ankle
27"
24"
21"
18"
15"
12"
9"
6"
3"
Ankle
Instep
...
UnAffected
(Left)
Affected
(Right)
...
Thigh*
...
...
...
Knee
...
Calf*
...
...
Ankle
Instep
*Largest Area