Please enable JavaScript in your browser to complete this form.Pt NameDOBAgeSexMFDateInsurerPhysicianServicePractitionerHTWTDiagnosisSideLeftRightBothShoe SizePrimary Problem/ area(s) of painUsual Regular Activities Date of InjuryMechanism of injuryPrevious Surgeries and DatesPhysical TherapyNoneOngoingForthcomingFrequencyTherapistOther TreatmentsLast Orthosis/ brace TypeMade byHow OldStill being used?YesNoProblems with last orthosisDesire of new orthosisKneevarumNeutralvalgumDegreeThigh (L)Knee (L) Calf (L) Ant. Drawerlow 0-5mmmod 5-10high 10+Measures Thigh (R) Knee (R) Calf (R) RearfootPronatedneutralSupinatedOrthotic Goalsjt stabilizationlimit ROMdecrease painred. risk of reinjuryfacilitate healingDesign Criteria needs custom fitneeds custom madecustom made sub option abnormal size/shapeneed long termhas delicate skinaccommodate deformityc/fit not availablecustom fit sub optionssize expected to changeneeds in rushcustom not necessaryPlanfit today from stockpt meas/ cast todayon holding pend approvalready in VPrSzsub options (fit today from stock) pt given instr'n on usept can show proper usefup inFup in Practitioner Email *Submit and Start Meas Form SubmitSave and Resume Later Your form entry has been saved View Your Saved Forms Copy Link
