Foot Orthotics
Initial Eval
Foot Orthotics
Initial Eval
1 - Note Section:
Px
Other relevant information for Px
Gender
Pick One
Patient Age
Patient Height
Weight in lbs
2-Note Section:
Dx
FO Common Dx
Please Select 1
Other Dx not listed
3 - Note Section:
Rx
Other Rx:
Prescription
Prescription
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
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.
