Floor Reaction, PTB, Anterior Removable Shell AFO

Access Legacy PDF work order. Legacy form will be accepted until Aug 15th.
Please do not print the Review page.

Scroll to the bottom, hit Complete and then download the work order.
NextGen Encounter ID:
FLOOR REACTION, PTB, ANTERIOR REMOVABLE SHELL AFO

Intake Information
Patient ID:
PO or Encounter #:
Clinician Name - Deprecated:
Clinician Name:

First NameLast Name
Fabrication Location:
HFN Rocky Hill (Cromwell) has relocated! Our new address is:
31 Inwood Rd, Rocky Hill, CT 06067
Other Fabrication Location:
Fab PCC #
Fab Location
Please enter a correct Fab PCC#
Clinician Email:
Please enter to receive confirmation.
Clinician Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
External
- Bilateral:
- Age:
- Bilateral Type:
- Affected Side:
- Bilateral Symmetrical:
  - Left and Right sides can have different Measurements
  - Same Alignment, Design and Finishing options
- Affected Side-Bilat Sym
- Affected Side-Bilat Asymmetrical
- Weight Unit:
- Weight:
- Weight:
- Diagnosis:
- Submission Type:
- Submission Type:
  - Plaster Cast: Negative or Positive
    
    Please include a printed Work Order with the cast when shipping.
- The Shipping section is now at the end of the form.

FLOOR REACTION, PTB, ANTERIOR REMOVABLE SHELL AFO

Configurator
Notes:

0/250
- Tuning: Is this device being tuned?
- Tuned Heading
- Casting block Height and Toe Ramp Angle measurements are recommended.
  If Heel Wedging alone is required, please proceed to the next page.
- Please indicate measurement unit:
- Tuning Ankle Alignment:
- Final Ankle Position (Ankle Angle):
- Set the Ankle in Degrees* ° of Dorsiflexion Plantarflexion*
- Ankle Degrees container
- Set to SVA of:
- Toe Ramp/Extension Angle:
- Set Heel Wedge To:
- Shoe Heel Height:
  Decimal value optional
- Shoe Heel Height:
  Decimal value optional
- Specified Amount:
  Decimal value optional
- Specified Amount:
  Decimal value optional
- Calculated
- SVA
- Specified Amount
- Set Heel Wedge to Container:
- Casting Block Height:
  Decimal Value Optional
- Casting Block Height:
  Decimal Value Optional
- External Heel Wedge Attachment:
- Go by:
- Please indicate measurement unit:
- Selected unit: {pleaseIndicate910}
- Left Selection
- Right Selection
- L - Finished Orthosis Height:
  Decimal value optional
- R - Finished Orthosis Height:
  Decimal value optional
- Finished Orthosis Height Container
- L - Finished Footplate length:
  Decimal value optional
- R- Finished Footplate length:
  Decimal value optional
- Finished Footplate Length Container
- L - MPT AP:
  Decimal value optional
- R - MPT AP:
  Decimal value optional
- MPT AP Container
- L - MPT to Floor:
  Decimal value optional
- R - MPT to Floor:
  Decimal value optional
- MPT to Floor Container
- L - Calf Circ:
  Decimal value optional
- R - Calf Circ:
  Decimal value optional
- Calf Circ Container
- L - Calf ML:
  Decimal value optional
- R - Calf ML:
  Decimal value optional
- Calf ML Container
- L - Ankle ML:
  Decimal value optional
- R - Ankle ML:
  Decimal value optional
- Ankle ML Container
- L - Met Head ML (Semi-weight bearing)::
  Decimal value optional
- R - Met Head ML (Semi-weight bearing)::
  Decimal value optional
- Met Head ML Container
- L - Ankle Joint Height:
  Decimal value optional
- R - Ankle Joint Height:
  Decimal value optional
- Ankle Joint Height Container
- L - Anatomical Foot Length (Weight Bearing):
  Decimal value optional
- R - Anatomical Foot Length (Weight Bearing):
  Decimal value optional
- Anatomical Foot Length Container
- L - Finished Orthosis Height:
  Decimal value optional
- R - Finished Orthosis Height:
  Decimal value optional
- L - Finished Footplate length:
  Decimal value optional
- R - Finished Footplate length:
  Decimal value optional
- L - MPT AP:
  Decimal value optional
- R - MPT AP:
  Decimal value optional
- L - MPT to Floor:
  Decimal value optional
- R - MPT to Floor:
  Decimal value optional
- L - Calf Circ:
  Decimal value optional
- R - Calf Circ:
  Decimal value optional
- L - Calf ML:
  Decimal value optional
- R - Calf ML:
  Decimal value optional
- L - Ankle ML:
  Decimal value optional
- R - Ankle ML:
  Decimal value optional
- L - Met Head ML (Semi-weight bearing):
  Decimal value optional
- R - Met Head ML (Semi-weight bearing):
  Decimal value optional
- L - Ankle Joint Height:
  Decimal value optional
- R - Ankle Joint Height:
  Decimal value optional
- L - Anatomical Foot Length (Weight Bearing):
  Decimal value optional
- R - Anatomical Foot Length (Weight Bearing):
  Decimal value optional
- i
  
  NEUTRAL is the Tibia perpendicular to the floor based on Heel Height.
- Ankle Alignment:
- Final Ankle Position:
- Set the Ankle in Degrees* ° of Dorsiflexion Plantarflexion*
- Ankle Degrees container
- Heel Height Accommodation:
- Forefoot Alignment:
- If "As Casted" Forefoot Alignment is required, please select "Other" and provided the as casted alignment.
- Forefoot Alignment Container:
- Final Forefoot Position:
- Set the Forefoot in Degrees* ° of Varus Valgus*
- Forefoot Degrees container
- Hindfoot Alignment
- Final Hindfoot Position:
- Set the Hindfoot in Degrees* ° of Inversion Eversion*
- Hindfoot Degrees container
- Buildups/Reductions:
- Standard Mods include:
  - 1/8" (3 mm) buildup at the Malleoli, Navicular and Base of the 5th.
  - 1/8" (3 mm) reduction at the Medial Longitudinal Arch Apex.
- Met Heads:
- Medial Malleolus:
- Lateral Malleolus:
- Navicular:
- Base of the 5th:
- Posterior Heel (pump bump):
- Medial Longitudinal Arch Apex Reduction:
- Dorsum
- Foot Mod Add ons:
- Foot Mod Add ons:
- Intrinsic Heel Skive:
- Skive Magnitude:
- Intrinsic Heel Skive requires external posting/wedging.
- Trimline Profile:
- - Standard: 1/8" deflection from the leg with extra accommodation at the malleoli to reduce edge pressure.
- - Gutter: Material added to create a "gutter" shape so the trimlines are inline with the apex of the buildups.
- Trimline Profile:
- Gutter Trimline Profile Location:
- Trimline Profile Location:
- Midfoot Trimline Default:
- Midfoot Trimline:
- Midfoot Trimline:
- Plastic Footplate Trimline Default:
- Plastic Footplate Trimline:
- Footplate Trimline:
- Forefoot Trimline Default:
- Forefoot Trimline:
- Forefoot Trimline:
- Additional Options:
- Location:
- Left Supramalleolar Extension:
- Right - Supramalleolar Extension:
- Posting/Wedging:
- External Heel Wedge:
- Specify Amount:
  Decimal value optional
- Specify Amount:
  Decimal value optional
- Posting options will not be available if a Heel Wedge is selected.
- {intrinsicHeel990} Intrinsic Heel Skive was selected.
- Heel Post:
- Heel Post Material:
- External Forefoot Post:
- External Forefoot Post Material:
- Ankle Joints
- Joints:
  
  Other
- Tamarack w/Dorsiflexion Assist:
- Posterior Stop (Optional):
  
  Other
- Plastic
- i
  
  Finished Plastic Thickness will be within 10% of the requested thickness.
- Plastic Type:
- Plastic Type:
- Anterior Shell Plastic Type:
- Finished Plastic Thickness:
- Anterior Finished Plastic Thickness:
- Finished Plastic Thickness:
- Anterior Finished Plastic Thickness:
- Plastic Color/Transfer:
- Description and Part #:
  Special Order Transfer Paper
- Special Order Transfer Papers can increase device turnaround time.
- Transfer Location:
- Stocked Transfer Paper #1:
- Stocked Transfers:
- Friddles Transfers:
- NewLimbits Transfers:
- Stocked Transfers Container #1
- NewLimbits Transfers Container #1
- Friddles Transfers Container #1
- Transfer # 1
- Stocked Transfer Paper #2:
- Please make a backup selection:
- Friddles Transfers:
- NewLimbits Transfers:
- Stocked Transfers Container #2
- NewLimbits Transfers Container #2
- Friddles Transfers Container #2
- Transfer # 2
- Duplicate Transfer
- PLEASE SELECT DIFFERENT OPTIONS FOR TRANSFER PAPERS.
- Anterior Shell Design:
- - Interlock Anterior shell will overlap the AFO trimlines (like a CROW Anterior Shell)
- - Sliding Anterior shell is free floating and can slide into the device.
- Reinforcement:
- Reinforcement:
- Inner Boot:
  
  Other
- Inner Boot Thickness:
- Inner Boot Thickness:
- L - Heel to Dorsum Circumference:
  Decimal value optional
- R - Heel to Dorsum Circumference:
  Decimal value optional
- Heel to Dorsum Circumference Container
- L - Instep Circumference:
  Decimal value optional
- R - Instep Circumference:
  Decimal value optional
- Instep Circumference Container
- L - Heel to Dorsum Circumference:
  Decimal value optional
- R - Heel to Dorsum Circumference:
  Decimal value optional
- L - Instep Circumference:
  Decimal value optional
- R - Instep Circumference:
  Decimal value optional
- Anterior Shell Padding Type:
- Anterior Shell Padding Thickness:
- Full Device Padding Type:
- Full Device Padding Thickness:
- Supramalleolar Ext. Padding Type:
- Supramalleolar Ext. Padding Thickness:
- Plantar Surface Padding Type:
- Plantar Surface Padding Thickness:
- Additional Padding
- Malleoli Padding:
- Malleoli Padding Type:
- Malleoli Padding Thickness:
- Calf Padding Type:
- Calf Padding Thickness:
- Navicular Padding Type:
- Navicular Padding Thickness:
- Empty
- Additional Padding Insertion:
- Fastener Type:
- Strap Type:
- Leather Strap Color:
- Dacron Strap Color:
- Velcro Strap Color:
- Calf Strap Width:
- Calf Strap Placement:
- Calf Strap:
- Anterior Shell Strap Width:
- Anterior Shell Strap:
- Instep Strap Width:
- Instep Strap Placement:
- Instep Strap:
- Corrective:
- Instep Strap Style:
- Add-Ons:
- Non-Skid Surface:

FLOOR REACTION, PTB, ANTERIOR REMOVABLE SHELL AFO

FLOOR REACTION, PTB, ANTERIOR REMOVABLE SHELL AFO

FLOOR REACTION, PTB, ANTERIOR REMOVABLE SHELL AFO

Intrinsic Heel Skive requires external posting/wedging.

Posting/Wedging:

Posting options will not be available if a Heel Wedge is selected.

Ankle Joints

Plastic

Special Order Transfer Papers can increase device turnaround time.

Additional Padding

FLOOR REACTION, PTB, ANTERIOR REMOVABLE SHELL AFO