Clinician :
Contact Number :
Site of Care :
Email Address:
Date :
Postal Address :
Client :
Conatct :
DOB:
Weight:
Postal Address:
Current Assessment:
Medical History:
Treatment Objective:
Order
Footwear :
Off the Shelf
Custom
For Off the Shelf :
With Modifications
Not Required
Orthoses :
With Orthoses
Not Required
If the orthoses are being manufactured by the clinician, please an allowance in the depth of the shoe to accommodate:
mm
Oedema
If the orthoses are being manufactured by the clinician, please an allowance in the depth of the shoe to accommodate:
3 mm
6 mm
9 mm
Other:
mm
Orthoses
Completed
Clinician to Complete (Supplied with Covers)
Material:
38 EVA
55 EVA
Thickness :
Left:
Heel:
mm
Ball:
mm
Toe:
mm
Right:
Heel:
mm
Ball:
mm
Toe:
mm
Type :
Contoured Foot
Flat Forefoot
Toe Filler
Offloading Required Indicate position and height
Plugs Required Indicate position
Footwear
Toe Shape:
Narrow
Comfort
DAV
Sandal
Broad
Make as a Pair
Match to Foot/Scan
Last Bottom
Normal
Rocker
Heel Pitch :
mm
Raise:
Internal
External
Combination
Raise Heights:
Heel:
mm
Sole:
mm
Toe:
mm
Tpye:
Boot
Shoe
Style:
Style Number:
Colour:
Upper Materials:
Lining:
Attach photos if required to match style
Boot Measurements:
Left(Height:
mm
Ankle Cire:
mm)
Right
(Height:
mm
Ankle Circ:
mm)
Fastening:
Laces
Velcro:Number of Straps:
Other:
Heel Counter:
Left:
Normal
Right:
Normal
Single (
Medial OR
Lateral)
Single (
Medial OR
Lateral)
Supra-Double
Supra-Double
Polypropylene Insert:
Left:
AFO:
Right:
AFO
Supracondylar
Supracondylar
Sole-only
Sole-only
Rockers:
Left:
Single Point Rocker
Two Point Rocker
Right:
Single Point Rocker
Two Point Rocker
Please indicate position and angle of each rocker
Sole:
Left:
Flat Wedge
Sole & Heel
Other
Right:
Flat Wedge
Sole & Heel
Other
Flares:
Left:
Medial:
mm
Lateral
mm
Right:
Medial
mm
Lateral
mm
Wedge:
Left:
Medial:
mm
Lateral
mm
Right:
Medial
mm
Lateral
mm
Sole:
Finished:
with final rubber attached
Unfinished:
Leave final rubber off
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