SMO Order Form

SMO Order Form
Patient Name
PO
Date

MonthDayYear
Date
Date Needed

MonthDayYear
Date
Practitioner
Phone/Email
Facility
Address
Side
Height
Weight
Age
Sex
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

StandardOpen-HeelBony ReliefToe-WalkingSub-MO
Alignment

Leave cast as isCorrect cast to neutralCorrect cast to specified below
Desired Sagittal Angle
Sagittal Angle

PlantarflexionDorsiflexion
Desired Hindfoot Angle
Hindfoot Angle

InversionEversion
Desired Forefoot Angle
Forefoot Angle

InversionEversion
Finished heel height
Tibial Inclination Angle
Modification Notes
Plastic Thickness

3/32"1/8"5/32"3/16"
Plastic

CoPoly (Standard)MPEPolyproOther
Plastic Color/Transfer Pattern
Hindfoot Posting

NoneFullMedialLateral
Hindfoot Posting Material

PlasticCrepeCork
Molded Inner Boot Thickness

3/32"1/8"
Molded Inner Boot Material

PuffLDPE (Low Density Polyethylene)MPE (Modified Polyethylene)OPTek FlexOrfitrans ExcelProflex w/ SiliconeOPTek Flex ComfortNorthvane
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

MalleoliArchNavicularPlantar SurfaceFull LiningOther
SMO Height/Trimlines

StandardDrawn on cast/modelOther
Foot Plate

FullSulcus3/4Surestep
Met Head Trimlines

1st Met Head In1st Met Head Out5th Met Head In5th Met Head Out
Strap Location

In-StepForefoot
Strap Color
Strap Material

UniMeshVelcro (Hook & Loop)Dacron-BackedVinyl-Backed
Strap Closure

D-Ring (standard)VelcroOther
Notes
Should be Empty:

SMO Order Form

Measurements

SMO Fabrication Information