KAFO Order Form
(269)-615-1643 | john@wamhoffmobilitylab.com
Order Information
Patient Name
*
PO
Date
/
Month
/
Day
Year
Date Needed
/
Month
/
Day
Year
Practitioner
*
Phone/Email
Facility
*
Address
*
Side
Please Select
Right
Left
Bilateral
Height
Weight
*
Age
Sex
Diagnosis
*
Enter patient diagnosis/reason for needing a KAFO(s).
Measurements
ML: Perineum
ML: Mid-thigh
ML: Lower-thigh
ML: Knee Center
*
ML: Largest Calf
ML: Supramalleolar
ML: Malleoli
ML: Metatarsal Heads
Circumference: Perineum
Circumference: Mid-thigh
Circumference: Lower-thigh
Circumference: Knee Center
Circumference: Largest Calf
Circumference: Supramalleolar
Length: Greater Trochanter - Floor
Length: Perineum - Floor
Length: Knee Center - Floor
*
Length: Fibular Head - Floor
Length: Heel - 1st Metatarsal Head
Length: Heel - Great Toe
*
Length: Medial Malleolus - Floor
KAFO Specifications
KAFO Type
Thermoplastic
Composite
Hybrid 1 - Composite Thish/Plastic AFO
Hybrid 2 - Plastic Thich/Composite AFO
Other
KAFO Orientation
Posterior Thigh + Posterior AFO
Posterior Thigh + Ground Reaction AFO
Anterior Thigh + Posterior AFO
Anterior Thigh + Ground Reaction AFO
Upright Orientation
Double Upright
Single Upright - Lateral
Single Upright - Medial
Alignment
Leave cast as is
Correct cast to neutral
Correct cast to specified angles below
Desired Sagittal Angle - Knee
Sagittal Angle - Knee
Flexion
Extension
Desired Sagittal Angle - Ankle
Sagittal Angle - Ankle
Plantarflexion
Dorsiflexion
Desired Coronal Angle - Knee
Coronal Angle - Knee
ABduction
ADduction
Desired Hindfoot Angle
Hindfoot Angle
Inversion
Eversion
Desired Forefoot Angle
Forefoot Angle
Inversion
Eversion
Finished Heel Height
Tibial Inclination Angle
Modification Notes
Plastic Thickness
1/8"
5/32"
3/16"
1/4"
Plastic
Polypro
CoPoly
ProComp
Composite Layup
Light Duty
Moderate Duty
Heavy Duty
Composite Type
Wet Lam
Pre-Preg
Material Color/Transfer/Design
Hindfoot Posting
None
Full
Medial
Lateral
Hindfoot Posting Material
Plastic
Crepe
Cork
Forefoot Posting
None
Full
Medial
Lateral
Forefoot Posting Material
Plastic
Crepe
Cork
Knee Joints
Upright Material
Aluminum
Stainless Steel
Ankle Joints
Tamarack
Tamarack Dorsi-Assist
Pivot
Double Action
Triple Action
Gaffney
Other
Posterior/PF Stop
PAS-100
Snapstop
X-Tension
PF Limiter
Other
Molded Inner Boot Thickness
3/32"
1/8"
Molded Inner Boot Material
Puff
LDPE (Low Density Polyethylene)
MPE (Modified Polyethylene)
OPTek Flex
Orfitrans Excel
Proflex w/ Silicone
OPTek Flex Comfort
Northvane
Other Additions
Quick Disconnect
Quick Release
Growth Release Bar
Flexible Tongue(s)
ClickReel
Wedging (specify below)
Soling
Other
Wedging
Padding Thickness
1/16"
1/8"
3/16"
1/4"
Padding Material
Puff (Shore 35)
P-Cell (Shore 25)
EVA (Shore 20)
Aliplast (Shore 15)
Other
Padding Location(s)
Proximal Calf
Malleoli
Arch
Navicular
Plantar Surface
Full Shin
Full Thigh
Full Lining
Other
Thigh Cuff Height
AFO Height
Trimlines
Standard
Other
Foot Plate
Full
Sulcus
3/4
Met Head Trimlines (Plastic)
1st Met Head In
1st Met Head Out
5th Met Head In
5th Met Head Out
Met Head Trimlines (Inner Boot)
1st Met Head In
1st Met Head Out
5th Met Head In
5th Met Head Out
Straps
Proximal Thigh
Distal Thigh
Proximal Calf
Supramalleolar
In-Step
Forefoot
Type a question
UniMesh
Velcro (Hook & Loop)
Dacron-backed
Vinyl-backed
Strap Closure
D-Ring
Velcro
Other
Strap Color
Please Select
Black
White
Gray
Beige
Royal Blue
Light Blue
Red
Orange
Purple
Pink
Green
Yellow
Notes
Enter any additional information or KAFO requests in this section.
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