Foot Orthotics
Delivery
Foot Orthotics
Delivery
1 - Note Section:
Px
Gender
Pick One
Male
Female
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Patient Age
Patient Height
Weight in lbs
Other relevant information for Px
Dx:
Diagnosis
2-Note Section:
Rx
Additional relevant info for Rx:
3 - Note Section:
Hx
Additional relevant information for hx:
4 - Note Section:
Hx:
5 - Note Section
Sx
How does the pt like the shoes and orthotics?
Ax:
Other relevant info for Ax:
6 - Note Section:
Sx:
Shoe type delivered in apt today
Orthotic type delivered today
Modifications made to the Foot Orthotics
No modifications were made
Modifications were made
Modifications made to the foot orthotic
Other Services Preformed during Appointment:
Did You educate the pt on the wear and care of the device?
Yes
No
Did you answer all of the pts questions?
Yes
No
7 - Note Section:
Ppx:
Other relevant information for ppx:
8 - Note Section:
Rtn:
Next visit:
Follow up as needed
Follow up apt set
Next Appointment:
