Foot Orthotics
Initial Eval
Foot Orthotics
Initial Eval
1 - Note Section:
Px
Other relevant information for Px
Gender
Pick One
Male
Female
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Patient Age
Patient Height
Weight in lbs
2-Note Section:
Dx
FO Common Dx
Please Select 1
M79.673 Pain in unspecified foot
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Other Dx not listed
3 - Note Section:
Rx
Other Rx:
Prescription
Prescription
1 Pair of orthotic footwear with custom foot orthotics
2 Pair of orthotic footwear with custom foot orthotics
Other
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4 - Note Section:
Hx:
Past shoes and inserts
chief complaint
Additional relevant information for hx:
5 - Note Section:
Ax
Measured Shoe size (left)
Measured Shoe size (right)
Wide
Wide
Medium (regular)
Wide
Extra Wide
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Currently wearing shoe size
1st pair of shoes with color
2nd Pair of shoes with color
Orthotic Build specifications
Additional relevant information
6 - Note Section:
Sx:
During Today's Appointment we did:
Took impressions of feet
measured pts feet
Other relevant information for sx:
7 - Note Section:
Ppx:
What I plan to do next
Order the shoes
order the custom inserts
include the custom inserts specifications from above
Other relevant information for ppx:
8 - Note Section:
Rtn:
Next steps
Once the shoes and inserts have been recieved, we will reach out to pt and schedule a delivery appointment.
