Clinician's Name
Clinician's Email
Date Prescribed
-
Day
-
Month
Year
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00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
:
Hour
00
05
10
15
20
25
30
35
40
45
50
55
Minutes
Patient Details
Name
First Name
Last Name
Patient ID
Weight (kg)
Shoe Size
Left and Right Foot Size Differs
Yes
No
Shoe Size
Please Select
Child - 8<
Child - 8
Child - 8.5
Child - 9
Child - 9.5
Child - 10
Child - 10.5
Child - 11
Child - 11.5
Child - 12
Child - 12.5
Child - 13
Child - 13.5
Adult - 1
Adult - 1.5
Adult - 2
Adult - 2.5
Adult - 3
Adult - 3.5
Adult - 4
Adult - 4.5
Adult - 5
Adult - 5.5
Adult - 6
Adult - 6.5
Adult - 7
Adult - 7.5
Adult - 8
Adult - 8.5
Adult - 9
Adult - 9.5
Adult - 10
Adult - 10.5
Adult - 11
Adult - 11.5
Adult - 12
Adult - 12.5
Adult - 13
Adult - 13.5
Adult - 14
Adult - 14.5
Adult - 15
Adult - 15.5
Adult - 15.5>
Left Foot Size
Please Select
Child - 8<
Child - 8
Child - 8.5
Child - 9
Child - 9.5
Child - 10
Child - 10.5
Child - 11
Child - 11.5
Child - 12
Child - 12.5
Child - 13
Child - 13.5
Adult - 1
Adult - 1.5
Adult - 2
Adult - 2.5
Adult - 3
Adult - 3.5
Adult - 4
Adult - 4.5
Adult - 5
Adult - 5.5
Adult - 6
Adult - 6.5
Adult - 7
Adult - 7.5
Adult - 8
Adult - 8.5
Adult - 9
Adult - 9.5
Adult - 10
Adult - 10.5
Adult - 11
Adult - 11.5
Adult - 12
Adult - 12.5
Adult - 13
Adult - 13.5
Adult - 14
Adult - 14.5
Adult - 15
Adult - 15.5
Adult - 15.5>
Right Foot Size
Please Select
Child - 8<
Child - 8
Child - 8.5
Child - 9
Child - 9.5
Child - 10
Child - 10.5
Child - 11
Child - 11.5
Child - 12
Child - 12.5
Child - 13
Child - 13.5
Adult - 1
Adult - 1.5
Adult - 2
Adult - 2.5
Adult - 3
Adult - 3.5
Adult - 4
Adult - 4.5
Adult - 5
Adult - 5.5
Adult - 6
Adult - 6.5
Adult - 7
Adult - 7.5
Adult - 8
Adult - 8.5
Adult - 9
Adult - 9.5
Adult - 10
Adult - 10.5
Adult - 11
Adult - 11.5
Adult - 12
Adult - 12.5
Adult - 13
Adult - 13.5
Adult - 14
Adult - 14.5
Adult - 15
Adult - 15.5
Adult - 15.5>
Prescription
Method of Casting
Please Select
Foam Box Impression
Slipper Sock
Fit of Orthotic
Please Select
Standard
Gent's Dress
Lady's Dress
Top Cover Length
Sulcus
Full-Length
Top Material Left
Please Select
40A (Beige)
40A (Red)
50A (Black)
60A (Red)
Top Material Right
Please Select
40A (Beige)
40A (Red)
50A (Black)
60A (Red)
Base Material Left
Please Select
40A (6mm)
40A (8mm)
50A (6mm)
50A (8mm)
60A (6mm)
60A (8mm)
Base Material Right
Please Select
40A (6mm)
40A (8mm)
50A (6mm)
50A (8mm)
60A (6mm)
60A (8mm)
Postings
Rearfoot Medial Left
Please Select
1°
2°
3°
4°
5°
Rearfoot Medial Right
Please Select
1°
2°
3°
4°
5°
Rearfoot Medial Left Density
Please Select
40
60
Rearfoot Medial Right Density
Please Select
40
60
Rearfoot Lateral Left
Please Select
1°
2°
3°
4°
5°
Rearfoot Lateral Right
Please Select
1°
2°
3°
4°
5°
Rearfoot Lateral Left Density
Please Select
40
60
Rearfoot Lateral Right Density
Please Select
40
60
Midfoot Arch Filler Left
Please Select
40
60
Midfoot Arch Filler Right
Please Select
40
60
Midfoot Arch to 1st MTPJ Left
Please Select
40
60
Midfoot Arch to 1st MTPJ Right
Please Select
40
60
Forefoot Lateral Wedge Left
Please Select
1°
2°
3°
4°
5°
Forefoot Lateral Wedge Right
Please Select
1°
2°
3°
4°
5°
Forefoot Lateral Wedge Left Density
Please Select
40
60
Forefoot Lateral Wedge Right Density
Please Select
40
60
1st MTPJ Cut Out Left
Met
Ray
1st MTPJ Cut Out Right
Met
Ray
Hallux Cut Out Left
Yes
Hallux Cut Out Right
Yes
Met Dome Left
Please Select
S
M
L
Met Dome Right
Please Select
S
M
L
Heel Raise Left
Please Select
1 mm
2 mm
3 mm
4 mm
5 mm
6 mm
7 mm
8 mm
9 mm
10 mm
11 mm
12 mm
13 mm
14 mm
15 mm
Heel Raise Right
Please Select
1 mm
2 mm
3 mm
4 mm
5 mm
6 mm
7 mm
8 mm
9 mm
10 mm
11 mm
12 mm
13 mm
14 mm
15 mm
Heel Raise Left Density
Please Select
40
60
Heel Raise Right Density
Please Select
40
60
Whole Base Wedge Medial Left
Please Select
1°
2°
3°
4°
5°
Whole Base Wedge Medial Right
Please Select
1°
2°
3°
4°
5°
Whole Base Wedge Medial Left Density
Please Select
40
60
Whole Base Wedge Medial Right Density
Please Select
40
60
Whole Base Wedge Lateral Left
Please Select
1°
2°
3°
4°
5°
Whole Base Wedge Lateral Right
Please Select
1°
2°
3°
4°
5°
Whole Base Wedge Lateral Left Density
Please Select
40
60
Whole Base Wedge Lateral Right Density
Please Select
40
60
STJ Axis Filler
Left
Right
STJ Axis Filler Left
Please Select
1 mm
2 mm
3 mm
4 mm
5 mm
STJ Axis Filler Right
Please Select
1 mm
2 mm
3 mm
4 mm
5 mm
STJ Axis Filler Left Density
Please Select
40
60
STJ Axis Filler Right Density
Please Select
40
60
Lateral STJ Filler
Left
Right
Lateral STJ Axis Filler Left
Please Select
1 mm
2 mm
3 mm
4 mm
5 mm
Lateral STJ Axis Filler Right
Please Select
1 mm
2 mm
3 mm
4 mm
5 mm
Lateral STJ Axis Filler Left Density
Please Select
40
60
Lateral STJ Axis Filler Right Density
Please Select
40
60
Adjustments:
Further Comments:
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