Custom Design Orthotic Prescription Form

Custom Design Orthotic Prescription Form

Custom Design Orthotic
Prescription Form
Patient Details
Podiatrist Details
Name:
Name:
Age:
Size:
Sex:
PO#
Address:
Footwear Type:
Phone:
Date:
Type
Traditional:
Concave Wedge:
Wedge:
Court: Hook
Cast Correction
Full Heel
( +/-Arch
)
Rear Foot:
Fore Foot:
Fill Technique
Inverted:
Mid:
L
R
Modified Root:
L
R
Min. Arch Fill
L
R
Max. Arch Fill
L
R
L
R
(Total)
Left
Right
( +/- )
( +/- )
Left Angle
Right Angle
Optional:
Shell Material
Cast Modifications
Medial Heel Skive:
S
M
L
Tri-Planar Heel Shave:
L
No Plaster Fill B/W 1/5:
Cuboid Notch:
S
L
L
M
L
Plantar 5th Ray Grind:
L
L
R
1st Ray
Accommodation:
L
R
R
R
R
R
Extra Heel
Expansion:
L
Medial Flare:
Medial Wrap:
mm
R
L
mm
L
Carbon Fibre (Superform)
EVA
6.0 mm
Semi-Rigid
Soft
5.0 mm
Semi-Flex
Medium
4.5 mm
Hard
4.0 mm
R
EVA Length
3.5 mm
L
R
3/4
3.0 mm
Web
2.5 mm
Other:
Plantar Fascial
Accommodation:
Polypropelene
Full
2.0 mm
R
Other:
Cover
Shell Modification
Heel Aperature:
S
M
L
L
R
Shape
Material
No Cover Polished:
Vinyl:
No Cover Rough:
Leather:
Standard
PS Vlies:
Heel Aperature Poron Button:
L
R
Heel Aperature Cambrelle Button:
L
R
1st Ray Cut-Out:
L
R
Standard Plus:
Lunasoft:
Lateral Plantar Grind:
L
R
Web:
Poron:
1.5
3.0
Gait Plate:
L
R
Full:
Spenco:
1.5
3.0
3.0 Red
Cambrelle Base:
Shell Shape
Other / Comments
Standard:
or Low Profile:
Heel Stabiliser
Full:
Right
Left
1/2:
Mini:
Return Date / Time
131-135 Atlantic Drive Keysborough Vic 3173 Australia
PO Box 4221 Dandenong South Vic 3164 Australia
Date:
Office Use Only
Office Use Only
Office Use Only
Received Date
Production Number
Scanned Confirmation
Time:
Tel. 1300 667 744 Fax. 1300 650 183
Eml. info@footwork.com.au
CDOPF200214