Prescription Form Footplate

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PRESCRIPTION FORM FOOTPLATE
ADMINISTRATIVE DETAILS
Date
/
/
Facility
PO No.
Orthotist E-mail
Appointment Date
/
/
END USER DETAILS
Client Reference
Left
Right
Bilateral Pair
Weight
Height
Activity Level
(KGS)
(CM)
BIOMECHANICAL OBJECTIVES
Resist heel lift in late stance (toe walking)
Limit 1st metatarsal extension (hallux rigitus)
Create ‘spring’ sensation at forefoot (sports)
Trans-metatarsal amputation protection
Metatarsal stress fracture protection
Morton’s Neuroma Protection
Other
DESIGN
Full Template Flat
Full Template Profile (13mm Heel Profile)
Mortons Template Flat
Mortons Template Profile (13mm Heel Profile)
OPTIONS
Pitch of footplate:
Shoe Sizing:
13mm Heel Pitch
UK shoe size
(DEFAULT)
Match heel pitch to cast provided
Match template traced on form
Match heel to shoe provided
Shoe provided to match
Make to heel pitch of
mm
STRUCTURAL OPTIONS
FLEX Flexible stiffness with little resistance to ground force
Toe Break Stiffness
Flex
Med
High
Rigid
MED Medium stiffness aiming to create a slight ‘spring’ sensation (Default)
Midfoot Stiffness
Flex
Med
High
Rigid
HIGH High stiffness with strong energy return to ground reaction force
Heel Stiffness
Flex
Med
High
Rigid
RIGID Ridgid stiffness with no movement or spring sensation
FOOT ORTHOSES REQUIRED
FOOT ORTHOSES NOTES
Flat cover material over footplate
Simple insole as template over prescription form
CADCAM insoles to specification
FINISH
Textured
(DEFAULT)
Gloss
(NOTES SECTION & GRID OVERLEAF)
Download this form at
CM SCALE
P 020 8693 3990
F 020 8693 5811
Orthotic Composites, Unit 2, 4C Tyrrell Rd, London, SE22 9NA
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