Metal AFO Fabrication
DMU
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DMU
Patient Name:
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Last Name
Encounter # / PO #:
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Practitioner:
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Clinic Location:
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Bloomington (317000)
Carmel (317100)
Charlotte (318500)
Charlotte (477800)
Columbus (317200)
Danville (317700)
Evansville (317300)
Greenwood (317400)
Holland (016800)
Indianapolis (317500)
Lexington (317800)
Lexington (007900)
London (317900)
Louisville I (318000)
Louisville II (318100)
Louisville III (008100)
Monroe (318700)
Mooresville (318800)
Morehead (318200)
Mt. Sterling (318300)
Paducah (318400)
Seymour (317600)
Somerset (028100)
Support Center (318900)
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Due Date:
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Metal AFO Fabrication
Patient Information
Affected Side:
*
Left
Right
Age:
*
Diagnosis:
*
Weight:
*
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Metal AFO Fabrication
Measurements
Left - Measurements:
*
Right - Measurements:
*
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Metal AFO Fabrication
Materials
Left - Uprights:
*
Double
Medial Only
Lateral Only
Right - Uprights:
*
Double
Medial Only
Lateral Only
Left - Upright Material:
*
Stainless - 3/16"x5/8"
Aluminum - 1/4"x5/8"
Aluminum - 3/16"x5/8"
Other
Right - Upright Material:
*
Stainless - 3/16"x5/8"
Aluminum - 1/4"x5/8"
Aluminum - 3/16"x5/8"
Other
Left - Stirrup:
*
Long Tongue
Split Caliper
Other
Right - Stirrup:
*
Long Tongue
Split Caliper
Other
Left - Joints:
*
Free Motion
Double Action
Other
Right - Joints:
*
Free Motion
Double Action
Other
Left - Double Action Pins/Springs:
All Pins
All Springs
Anterior Pins / Posterior Springs
Posterior Pins / Anterior Springs
Right - Double Action Pins/Springs:
All Pins
All Springs
Anterior Pins / Posterior Springs
Posterior Pins / Anterior Springs
Left - Calf Band Width:
*
1.5"
2"
Right - Calf Band Width:
*
1.5"
2"
Left - Calf Band Color:
*
Black
White
Brown
Right - Calf Band Color:
*
Black
White
Brown
Left - Calf Band Closure:
*
Velcro
Buckle
Right - Calf Band Closure:
*
Velcro
Buckle
Left - T-Strap Location:
*
None
Medial
Lateral
Right - T-Strap Location:
*
None
Medial
Lateral
Left - T-Strap Color:
Black
White
Brown
Right - T-Strap Color:
Black
White
Brown
Left - T-Strap Closure:
Buckle
Velcro
Right - T-Strap Closure:
Buckle
Velcro
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Metal AFO Fabrication
Notes
I would like a phone call to discuss this project prior to starting fabrication:
Yes
Notes (include any shoe modifications and additional requests here):
0/50
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