SMO Order Form
Patient Name
PO
Date
/
Month
/
Day
Year
Date
Date Needed
/
Month
/
Day
Year
Date
Practitioner
Phone/Email
Facility
Address
Side
Please Select
Right
Left
Bilateral
Height
Weight
Age
Sex
Please Select
Male
Female
Unspecified
Diagnosis
Measurements
Circumference - Largest Calf
Circumference - Supramalleolar
Circumference - In-Step
Circumference - Dorsum of Foot
ML - Malleoli
ML - Met Heads
Height - Medial Malleolus
Height - Lateral Malleolus
Length - Heel to 1st Met Head (Apex)
Length - Heel to Great Toe
Length - Heel to 5th Met Head (Apex)
Length - Heel to 5th Toe
Fibular Head to Floor
SMO Fabrication Information
SMO Type
Standard
Open-Heel
Bony Relief
Toe-Walking
Sub-MO
Alignment
Leave cast as is
Correct cast to neutral
Correct cast to specified below
Desired Sagittal Angle
Sagittal Angle
Plantarflexion
Dorsiflexion
Desired Hindfoot Angle
Hindfoot Angle
Inversion
Eversion
Desired Forefoot Angle
Forefoot Angle
Inversion
Eversion
Finished heel height
Tibial Inclination Angle
Modification Notes
Plastic Thickness
3/32"
1/8"
5/32"
3/16"
Plastic
CoPoly (Standard)
MPE
Polypro
Other
Plastic Color/Transfer Pattern
Hindfoot Posting
None
Full
Medial
Lateral
Hindfoot Posting Material
Plastic
Crepe
Cork
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
(I.e. reinforcements, etc.)
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
Malleoli
Arch
Navicular
Plantar Surface
Full Lining
Other
SMO Height/Trimlines
Standard
Drawn on cast/model
Other
Foot Plate
Full
Sulcus
3/4
Surestep
Met Head Trimlines
1st Met Head In
1st Met Head Out
5th Met Head In
5th Met Head Out
Strap Location
In-Step
Forefoot
Strap Color
Please Select
Black
White
Gray
Beige
Royal Blue
Light Blue
Red
Orange
Purple
Pink
Green
Yellow
Strap Material
UniMesh
Velcro (Hook & Loop)
Dacron-Backed
Vinyl-Backed
Strap Closure
D-Ring (standard)
Velcro
Other
Notes
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