AXIAL ORTHOTIC DOCUMENTATION WORKSHEET
Park Avenue Orthotics, Inc.
Prescribing Physician
Patient Name
Clinician Name
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Orthotic Dispensed
Thoracic Cage (10-12) Circumference
Hip Circumference
Waist Circumference
S5/C01-T9 I-S Length
Hip-Shoulder I-S Length
Distal Clavicle M-L Length
Orthotic Primary Use
Bony Prominences
Soft Tissue Conditions
Other Examination Observations
Clinician Notes
Appointment Start Time
Appointment End Time
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