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Final impressions (diagnosis/prognosis/justification)

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Management

1. INJURY (eg. pharmacological or physical therapy required) ........................................................ ................................................................................................................................................. 2. EXERCISE THERAPY ............................................................................................................ ................................................................................................................................................. 3. ACTIVITY MODIFICATION ...................................................................................................... ................................................................................................................................................ 4. OTHER EXTERNAL REFERRALS .......................................................................................... ................................................................................................................................................ 5.ORTHOSIS PRESCRIPTION CORRECTED CALCANEAL POSITION: LEFT ________° INV / EV RIGHT ________° INV / EV STYLE: .................................................................................................................................... (cushioning, pressure relief, pre-formed, moulded non-cast, moulded cast or functional foot orthosis [Root balance, modified Root, inverted, medial heel skive, DC wedge, hybrid]) MATERIAL:    4MM POLYPROP    EVA    OTHER................................... COVER:        VINYL             3MM PORON    CAMBRELLE EXTENSIONS:............................................................................................................................ HEEL PITCH:.................. SHELL MODIFICATIONS:..................................................................... 6. FOOTWEAR:.......................................................................................................................... 7. OTHER ADVICE:..................................................................................................................... ................................................................................................................................................. .................................................................................................................................................

DATE OF ISSUE: ........................................................................... PAYMENT: .........................
STUDENT (print name) ...............................................	CLINICIAN (signature) ...............................................	ASSESSMENT DATE: ................................................

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©2001 Kirsten Whaley, Fiona Berry & Adam Bird