Cast Evaluation Orthoses sent to Required Not Required Podiatrist Clinic Cast Bisection Date Use Given Lines Lab Discretion Material Pouring Instructions Polypropylene 3.0mm 4.0mm Pour Vertical L R 5.0mm Pour Inverted °L °R EVA Shell Full Length Pour Everted °L °R Trilaminate Full Length Forefoot Correction TL2100 Semi Rigid Rigid No Forefoot Correction L R Orthotic Shape Balance Forefoot to Perpendicular L R Standard Grind L R Intrinsic Posting L R Narrow Grind L R Extrinsic Posting L R Wide Grind L R Accommodation Medial Flange L R Cuboid Filler L R Lateral Flange L R Styloid Process L R Morton’s Extension L R No Filler 2 – 4 (Met Dome) L R Slimthotic type 1 – 3 L R Plantar Fascia L mm R mm 1 – 5 L R Lateral Expansion minimal standard maximum Heel Aperture L R Heel cup depth Arch fill ° Lab Discretion ° Minimal Left: Med mm Lat mm Right: Med mm Lat mm Specify Supplier (see supplier list) Heel Posting Extensions/Covers No Posting L R Shell To Sulcus Full Length Thin Heels to Min. Thickness L R Vinyl Intrinsic L R Leather Extrinsic L R PPT 1.5mm Left ° Inverted with °motion PPT 3mm Right ° Inverted with °motion Spenco 1.5mm Heel Flare Medial Lateral L R Spenco 3mm Medial Skive Luna Soft 2mm Left 2.0mm 4.0mm 6.0mm Luna Soft 3mm Right 2.0mm 4.0mm 6.0mm X-Static 3mm Posting Material Eva Other Specify Other Recommendations Supplier details Phone Medical Grade Footwear Required (please tick below) Left Right Bilateral Prefabricated ‘Off-the-shelf’ footwear with specialised features such as extra depth/width.
Cast Evaluation Required Not Required Cast Bisection Use Given Lines Lab Discretion Pouring Instructions Pour Vertical L R Pour Inverted °L °R Pour Everted °L °R Forefoot Correction No Forefoot Correction L R Balance Forefoot to Perpendicular L R Intrinsic Posting L R Extrinsic Posting L R Accommodation Cuboid Filler L R Styloid Process L R No Filler 2 – 4 (Met Dome) L R Plantar Fascia L mm R mm Lateral Expansion minimal standard maximum Arch fill ° Lab Discretion ° Minimal Specify Supplier (see supplier list) Orthoses sent to Podiatrist Clinic Date Material Polypropylene 3.0mm 4.0mm 5.0mm EVA Shell Full Length Trilaminate Full Length TL2100 Semi Rigid Rigid Orthotic Shape Standard Grind L R Narrow Grind L R Wide Grind L R Medial Flange L R Lateral Flange L R Morton’s Extension L R Slimthotic type 1 – 3 L R 1 – 5 L R Heel Aperture L R Heel cup depth Left: Med mm Lat mm Right: Med mm Lat mm Heel Posting No Posting L R Thin Heels to Min. Thickness L R Intrinsic L R Extrinsic L R Left ° Inverted with °motion Right ° Inverted with °motion Heel Flare Medial Lateral L R Medial Skive Left 2.0mm 4.0mm 6.0mm Right 2.0mm 4.0mm 6.0mm Posting Material Eva Other Extensions/Covers Shell To Sulcus Full Length Vinyl Leather PPT 1.5mm PPT 3mm Spenco 1.5mm Spenco 3mm Luna Soft 2mm Luna Soft 3mm X-Static 3mm Specify Other Recommendations Supplier details Phone Medical Grade Footwear Required (please tick below) Left Right Bilateral Prefabricated ‘Off-the-shelf’ footwear with specialised features such as extra depth/width.
Foot-Ankle-Orthoses-Medical-Grade-Footwear-Assessment-Form.docx