Please enable JavaScript in your browser to complete this form.For Office Use OnlyDate InDate OutNumber Patient InformationName *FirstLastWeight Lbs. *Gender *Shoe Size *Type of Shoes * Biomechanical Examination FindingsArch Height: Non-Weight BearingHighMeduimLowArch Height: Weight BearingHighMeduimLowRight FootLeft FootMetatarsal AdductusRear Foot varus / valgusFore Foot varus / valgusGait Pattern: In toe / ourt toe / straightHallux ValgusHallux LimitusHallux RigidusPas Planus / Pes CavusRight FootLeft Foot TYPES OF ORTHOTICSSport MedixCasual MedixAccommodative MedixRobot WhitmanCF Sport MedixMarathonDressDiabeticXT Sport MedixCF Casual MedixSuper FlexDress SlenderSoft Comfort XT Casual MedixSafety MedixCobra PatternUCBLXT Dress Medix Types of Top CoverMicrocellBlackNavyRedGreenBrownYellowSportBlackNavyGreenRedBambooVinylBlackNavyBrownRedGreyLeatherBlackBrownBeigeX StaticBlackBeige Type of Shell and CushionDeep Heel Cup10mm12mm15mmOther LengthFull LengthSulcus3/4(lo Mels)CushionNone2mm3mmOtherType of ShellRigid(XT / CF)Semi RigidSoft (EVA) ModificationsHeel Spur PadRightLeftHeel CushionRightLeftMet Pad(1, 2, 3, 4, 5) Right(1, 2, 3, 4, 5) LeftMet Bar Pad(1, 2, 3, 4, 5) Right(1, 2, 3, 4, 5) LeftToe CrestRightLeftLateral ClipRightLeftCuboid PadRightLeftHigh Medial FlangeRightLeftHigh LiftLeftRightReinforce ArchLeftRightRare Foot PostingLeftRightNavicular PadRightLeftScaphoid PadRightLeftReverse Morton ExtensionRightLeftMorton's ExtensionRightLeftU Cut Out(1, 2, 3, 4, 5) Right(1, 2, 3, 4, 5) LeftExtrinsic Fore Foot Posting (Varus)RightEnter Value in mmExtrinsic Fore Foot Posting (Varus) LeftEnter Value in mm SHELL MODIFICATIONSHeel Center PocketRightLeft1st Met Cut OutRightLeft1st Ray Cut OutRightLeftFascia GroveRightLeftInduce in-toeingInduce out-toeing Kirby Skive Left MedialRight MedialKirby Skive Left MedialKirby Skive Right Medial Kirby SkiveLeft LateralRight LateralKirby Skive Left LateralKirby Skive Right LateralAdditional RequestShoes OrderFirstMiddleLastSubmit
