TF ESR (Thermoformed Energy Storing & Returning) AFO

  • Access Legacy PDF work order. Legacy form will be accepted until Nov 1st. 

  • Please do not print the Review page.

    Scroll to the bottom, hit Complete and then download the work order. 

  • TF ESR (Thermoformed Energy Storing & Returning) AFO

    Intake Information
  • Format: (000) 000-0000.
    • Patient Information: 

    • 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.

  • TF ESR AFO

    Configurator
  • 0/250
    • Casting: 

    • TWO STAGE CAST IS REQUIRED 

    • Image field 1226
    • Image field 1224
    • Image field 1228

    • ALIGNMENT CASTING BLOCK:

    • Toe Ramp Angle:

      • Low < 10° – household ambulators with limited community ambulation
      • Moderate 12-15° – community ambulator
      • High 15-30° – active community ambulators
    • Measurements: 
    • Patient Measurements
    • Patient Measurements

    • Please enter a value between 25 cm and 60 cm. You will not be able to proceed otherwise.

    • Alignment: 

    • i

      NEUTRAL is the Tibia perpendicular to the floor based on Heel Height. 

    • Final Forefoot Position:

    • Set the Forefoot in   *   ° of      *        

    • Final Hindfoot Position:

    • Set the Hindfoot in   *   ° of      *        

    • Design Criteria: 

    • MANUAL MUSCLE TESTS:

      Strength

    • Image field 1243
    • Image field 1246
    • Image field 1248

    • Observational Gait Analysis:

    • Biomechanical Objectives:

    • Image field 1260
    • Image field 1261
    • Image field 1262

    • Mild Control: provides minimal resistance to tibial advancement in stance.
      MMT: DF ≤ 3, PF ≥ 4, KE ≥ 4

    •  Moderate Control: provides mod. resistance to tibial advancement in stance.
      MMT: DF ≤ 3, PF ≤ 4, KE ≥ 4

    •  Firm Control: provides firm resistance to tibial advancement in stance.
      MMT: DF ≤ 3, PF ≤ 3, KE ≥ 4

    • Modifications/Trimlines: 

    • 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. 
    • Image field 1047
    • Materials/Design: 

    • NOTE: No variation in design at this time.

    • Image field 1082
    • Finishing: 

  • TF ESR AFO

    Notes
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  • Daily HFN Capacity

  • {requestedInoffice}{requestedInoffice1217}{requestedInoffice1281}{requestedInoffice1282}

    • Requested In-Office Date: 
    • Image field 1285

    • Clinicians can still coordinate special in-office requests by emailing:
      HFN_Hypercare@hanger.com

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