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Weight (lbs): Height (inches): Male or Female: Age:
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Diagnosis:
Pair: Right: Left:
Shoe: Size: Type: Heel Height:
LEVYTM Levy Balancer Levy Shaffer Levy EVA Mold Levy Dressthotic Levy Met-Thotic Levy Cork Mold Levy Plasta-Mold
PRO-WALKER Bio-Step Perfect-Step
BIO-SPORT Plush Ortholens Graphite
RAPPELTM M.D.I M.D.II M.D.III
L&RTM L&R Carboplast L&R Ortholen II L&R Whitman L&R U.C.B.L. *NEW* - A5513 3 for $99 - 35 Durometer EVA and Pink Plastazote
Metatarsal Head Sulcus Full Length
Low Medium High
Length Full Sulcus Meta Materials Leather Vinyl STS Anti-Shox Plastazote Other Materials:
Non-Weight Bearing Semi-Weight Bearing Full-Weight Bearing
Leather EVA Plastazote Thermocork Ortholen II: Semi Rigid Flexible Carboplast: Rigid Semi Rigid Other Materials:
Deep Heel Cup (14mm) Standard Heel Cup (10mm) Shallow Heel Cup (6mm) Metatarsal Raise Low Medium High Firm Soft Cut Outs (mark on cast or form) Heel Spur Pad R L Rubber Heel Pad R L Toe Crest R L Bunion Flange R L Mortons Extension R L Cuboid Raise R L Limb Length Discrepancy R L Heel Raise R L Other Additions:
Cork Rubber Steel Springs (amount): Other:
Post According to Cast (neutral) Post as Below Rearfoot: Medial R: Medial L: Lateral R: Lateral L: Forefoot: Medial R: Medial L: Lateral R: Lateral L:
Upload foot scan: Right (max size: 1.5mb • type: .fsn, .jpg, .zip):
Upload foot scan: Left (max size: 1.5mb • type: .fsn, .jpg, .zip):
