Full Name Required
Phone Number
Email Address Required
Your Area (prefecture) Required
Select a Prefecture
Hokkaido
Aomori
Iwate
Miyagi
Akita
Yamagata
Fukushima
Ibaraki
Tochigi
Gunma
Saitama
Chiba
Tokyo
Kanagawa
Niigata
Toyama
Ishikawa
Fukui
Yamanashi
Nagano
Gifu
Shizuoka
Aichi
Mie
Shiga
Kyoto
Osaka
Hyogo
Nara
Wakayama
Tottori
Shimane
Okayama
Hiroshima
Yamaguchi
Tokushima
Kagawa
Ehime
Kochi
Fukuoka
Saga
Nagasaki
Kumamoto
Oita
Miyazaki
Kagoshima
Okinawa
Age
years
weight (kg)Required
kg
Height (cm) Required
cm
Prosthesis history (years of use) Required
years
Amputated Limb Required
Right
Left
Both Sides
Types of Knee Joints (for those who have them) Required
(If you are unsure, please write [Unknown].)
Prosthesis usage: Required About
Select usage time
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
hours
Usage of prosthesis Required
Also used at home
Do not use at home
Only used for company round trips
Use public transportation
Exercise regularly
Everyday Life Required
You can change the walking speed
You can sprint at traffic lights
etc.
You can walk even if it is uneven
Prosthesis Mfg. / Person in charge Required
(Please note that we will contact the prosthesis manufacturer in charge.)
