AFO Measurement Form
Patient Information
Patient Name:
 
Age:
 
Weight:
 
Shoe Size:
 
Diagnosis:
 
Side:
 
Height:
 
Sex:
 
Cast Information
As Cast:
 
90°:
 
Has Cast Been Taken In Neutral Alignment?
 
Planter Flexed:
 
Tibia To Floor Angle Of:
 
Dorsiflexed:
 
With A Pitch Of:
 
Positive Cast Information
 
Trimlines
Height of AFO:
 
Ground Reaction:
 
Solid Ankle:
 
Other:
 
PLS:
 
With a Pitch of:
 
Additional Information
Materials & Design
Material:
 
Material Thickness:
 
Transfer Option 1:
 
Specify Other:
 
Colour:
 
Transfer Option 2:
 
Reinforcement
Reinforcement:
 
Additional Information:
 
Joints
Hinged Metal Type:
 
Hinged Plastic Type:
 
Strapping Requirements
R/pull Velcro:
Lap Over Velcro:
Lay On Velcro:
Backed Velcro:
Elastic:
Padded Straps:
Lining / Padding Requirements
Line Calf Plasterzote / Pelite:
 
Padded Over Malleoli:
 
Full Lining Plasterzote / Pelite:
 
Other Areas:
 
Order
Date required:
 
Your name:
 
Phone:
 
Delivery / Collection:
 
Company:
 
Mobile:
 
Aftercare Leaflet?
 
Job Title:
 
Email:
 

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With over 30 years’ experience working with Orthotists, the NHS and Private Hospitals, we are experts in the manufacture of custom-made Orthoses and dedicated to shaping lives.

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