LOWER EXTREMITY 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
Length Heel-Toe
Length Floor-Knee Center
Circumference Thigh
Circumference Calf
M-L Knee Center
M-L Ankle
Orthotic Primary Use
Bony Prominences
Soft Tissue Conditions
Other Examination Observations
Clinician Notes
Appointment Start Time
Appointment End Time
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