Today’s Date :

Due date :

Patient Name :

Male Female

Referred By :

Clinic Location :

Contact No :

Shoe Type :

Model

Size

Choose Your Pedorthic Modification (Please indicate on diagrams below)

Heel Raise :

L mm

R mm

Stretching :(mark on shoe) L R

Full-Length Raise :

L mm

R mm(Please indicate on diagrams below)

Buttress :

L

R

Medial

Lateral

Moderate

Extreme

Relasting :

L mm

L mm

Rocker Sole :

L mm

R mm(Please indicate on diagrams below)

Sole Flare :

L mm

R mm

Medial

Lateral

If you want to mark positions on below Shoe Pictures, please Print it, Mark It and send scan copy to info@myshoedr.com.au

Choose Your Shoe Modification (Please indicate on diagrams below)

Resole :

L mm

R mm

Density : Medium Hard

Strap Lengthening :

L mm

R mm

Heel Collar : L R

Haglund Bump Relief :

L mm

R mm

Velcro Replacement : L R

Colour Change :

Patient ID :

Shoe Conversion :

Lawn Bowls

Golf

Cricket (refer to www.customcricketshoes.com)

Comments

OFFICE USE ONLY