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Date of birth

DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / MM 01 02 03 04 05 06 07 08 09 10 11 12 / YYYY 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

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Membership details

Type of membership *

Online member - FreeFull member - £15Full member (Abroad) - £25Life member - £150Life member (Abroad) - £250

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Limb loss details

Are you an amputee? *

YesNo

Reason for limb loss *

Select…CongenitalCancer/SarcomaDiabetesIndustrial accidentInfectionMeningitisRoad traffic accidentSepticaemia/Blood diseaseVascularTrauma - otherIllness - other

Type of surgery/Limb loss *

Select…Congenital limb loss - Limb loss from birthTraumatic amputation - emergency or unplanned surgery/amputationElective amputation - medically planned/scheduled surgery

Date of limb loss *

DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / MM 01 02 03 04 05 06 07 08 09 10 11 12 / YYYY 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Level of limb loss *

Lower limb

Right through hip
Right above knee (RAK)
Right through knee (RTK)
Right below knee (RBK)
Right ankle/partial foot
Left through hip
Left above knee (LAK)
Left through knee (LTK)
Left below knee (LBK)
Left ankle/partial foot

Upper limb

Right through shoulder
Right above elbow (RAE)
Right below elbow (RBE)
Right wrist/partial hand
Left through shoulder
Left above elbow (LAE)
Left below elbow (LBE)
Left wrist/partial hand

Please select as many as apply.

Which limb centre do you attend? *

Select…AberdeenBelfastBirminghamBrightonBristolCambridgeCardiffCarlisleCharing CrossClevelandCrystal PalaceDerbyDorsetDorset OrthopaedicDundeeEdinburghExeterGillingham (Kent)GlasgowHarold Wood (Essex)HullInvernessIsle Of WightLeedsLeicesterLincoln (Nottingham Satellite Centre)LiverpoolLuton and DunstableManchesterNewcastleNorthamptonNorwichNottinghamNuffield (Oxford)PACEPlymouthPortsmouthPrestonProActive ProstheticsRoehamptonSheffieldStanmoreStoke-On-TrentSwanseaW D SpenceWirralWolverhamptonWrexhamOther

If other, please state

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Established 1983 | The Limbless Association, Jubilee House, 3 The Drive, Warley Hil, Brentwood, CM13 3FR,
Tel: 01277 725 182 | Charity No: 803533 | Companies No: 02487661 | Legal | Privacy