Becker Orthometry Forms

3495 Sec2.
1 HKAFO 2/19/05 3:48 PM Page 2
HIP-KNEE-ANKLE-FOOT ORTHOSES (HKAFO)
KAFO/HKAFO ORTHOMETRY FORM:

Todays Date: _____________________________________________
Patient: ___________________________________________________
Facility: ___________________________________________________
Age: ______ Sex: ______ Ht: ______
Street: ____________________________________________________
Diagnosis: ________________________________________________
City: _____________________________ State: _____ Zip:_________
______________________________________________________
Orthotist: _________________________________________________
Delivery Date: _____________________________________________
Phone Number: ___________________________________________
PO Number: ______________________________________________
Wt: ______
MEASUREMENTS: Inches Centimeters
Ankle
Knee
Varus
Valgus
Varum
Valgum
Flexible
Rigid
Flexible
Rigid
Degrees: __________________ Degrees: __________________
Toe Out
Toe In
Hyperextended
Medial Plane
Knee Flexion Contracture
Lateral Plane
Degrees: __________________
Degrees: __________________
Heel Height: _______________
2.1.4
BeckerOrthopedic.com
Phone:
Fax:
800-521-2192
800-923-2537
3495 Sec2.1 HKAFO 2/19/05 3:48 PM Page 3
KAFO/HKAFO ORTHOMETRY FORM CONTINUED:

Todays Date: _____________________________________________
Patient: ___________________________________________________
Facility: ___________________________________________________
Age: ______ Sex: ______ Ht: ______
Street: ____________________________________________________
Diagnosis: ________________________________________________
City: _____________________________ State: _____ Zip:_________
______________________________________________________
Orthotist: _________________________________________________
Delivery Date: _____________________________________________
Phone Number: ___________________________________________
PO Number: ______________________________________________
MATERIAL: Thermoplastic Metal and Leather
TYPE: KAFO HKAFO
Thermoplastic Options
Metal and Leather Options
Plastic (select one from each column)

Type
Thickness
Location
Flares
Polypropylene
1/8"
Anterior
Proximal
Copolymer
5/32"
Posterior
Medial
Polyethylene
3/16"
Lateral
1/4"
Leather (select one from each column)

Color
Closure
T-Strap
Knee Pad Condyle Pad
Black
Hook & Medial 3-Buckle Round*
Beige
Loop
Lateral 4-Buckle Pear
Smoked Elk Leather None
5-Buckle * Cannot
Brown
Strap &
use with
White
Buckle
1002 KJT
Correct cast to: _____________________
Do not correct cast
Liner (select one from each column)

Type
Thickness
Location
Aliplast
1/8"
Thigh
Posterior
Med-Density Pelite
5/32"
Anterior
Foot Plate
Heavy-Density Pelite 3/16"
Plantar Surface
1/4"
Other _________________
Ankle Joints (select type)

Dorsiflexion Assist
Dorsiflexion Plus Assist
Slim Line Double Action
Original Double Action
Standard Action
Size: A (Adult)
B (Youth)
Stirrup (select type)

Solid
Solid Wide Flange
Split
UCBL
Other __________
C (Child)
Range of Motion
Tamarack
Tamarack Dorsi Assist
Tamarack Variable Assist
Tamarack Clevisphere
Oklahoma (Polypro)
Oklahoma (Heavy Duty Nylon)
Size: A (Adult)
B (Youth)
655
755
Gillette
Gillette Heavy Duty
Gillette Dorsi Assist
Camber Axis Hinge
Other __________________
__________________________
C (Child)
Posterior Stops
795 Other ________________
None
Plantarflexion _______________ Dorsiflexion _______________
Hip Joint Options

Hip Joints (select one from each column)
Please see catalog section 3 for model numbers
Type
Free Motion
Ring Lock
Adjustable R.O.M.
Model Number: ________________
Knee Joint Options
Specials
Knee Joints (select one from each column)
Growth
Adjustments
Please see catalog section 4 for model numbers
Type
Material
Size
A (Adult)
B (Youth)
C (Child)
I (Infant)
Laminated
Thigh
Size
Upright Finish
AK
Anterior Cuff
Free Motion
E-Knee (9001)
Aluminum
1/4"x 3/4"
(Select Type)
BK
Posterior Cuff
Ring Lock
LR-9002 (9002)
Stainless Steel
3/16"x 3/4" High Buff
Lever Lock (Bail) G-Knee (9003)
Titanium*
1/4"x 5/8"
Ratchet Lock
Carbon Fiber
3/16"x 5/8"
Model Number: _________________
(9003 only)
* Not available on
Lateral
Both
Thermoclad
3/16"x 1/2" Black

1/8"x 1/2"
White
Blue
all Joints
Contoured: Medial
Bead Blast
None
Additional add-ons
Ball Catch
Thigh Lacer
Calf Lacer
HD Lever Release Kit
SS Footplate (please provide cast)
Tongue: AK BK
Other:___________________________
LEG: Left Right Bilateral
Wt: ______
Additional Instructions:
Phone:
Fax:
800-521-2192
800-923-2537
2.1.5
3495 Sec2.1 HKAFO 2/19/05 3:48 PM Page 5
RGO ORTHOMETRY FORM

Todays Date: _____________________________________________
Patient: ___________________________________________________
Facility: ___________________________________________________
Age: ______ Sex: ______ Ht: ______
Street: ____________________________________________________
Diagnosis: ________________________________________________
City: _____________________________ State: _____ Zip:_________
______________________________________________________
Orthotist: _________________________________________________
Delivery Date: _____________________________________________
Phone Number: ___________________________________________
PO Number: ______________________________________________
Wt: ______
328 Iso-Metric Pelvic section only
329 Bio-Metric Pelvic section only
328-K Iso-Metric RGO with KAFOs
329-K Bio-Metric RGO with KAFOs
328-A Iso-Metric with AFOs
329-A Bio-Metric with AFOs
Plastic (Kydex): Ivory

Liner: White
Chest Straps: White
Black
Beige
Gray
Blue
Beige
Rainbow
Pink
Black
ISO-Metric System
Options: Padded Strap Abdominal Strap Extra Liner Vacuum Formed TLSO
Please Complete Entire Orthometry Form For Best Fit

MEASUREMENTS: Inches Centimeters Millimeters
CIRCUMFERENCES
M-L
DIAMETERS
BIO-Metric System
LENGTHS
PROXIMAL
ASPECT
XYPHOID
PROCESS
PROXIMAL
ASPECT
to WAIST
WAIST
HIP JOINT
CENTER
WAIST to
HIP JOINT
CENTER
Lordosis
ISCHIAL
TUBEROSITY
KNEE AXIS
FIBULAR NECK
HJC to
Gluteus Maximus
ANKLE
AXIS
Pelvic Section
Phone:
Fax:
800-521-2192
800-923-2537
2.1.7
3495 Sec2.3 9000 KAFO 2/19/05 3:46 PM Page 7
UTX ORTHOSIS SELECTION PROTOCOL FORM

This protocol needs to be applied in conjunction with the manual for UTX orthoses
Patient: ___________________________________________________
Facility: ___________________________________________________
Age: ______ Sex: ______ Ht: ______
Street: ____________________________________________________
Diagnosis: ________________________________________________
City: _____________________________ State: _____ Zip:_________
___________________________________________________________
Orthotist: _________________________________________________
Delivery Date: _____________________________________________
Phone Number: ___________________________________________
PO Number: ______________________________________________
When all
boxes are
checked,
continue
with
STABIL
0
Function of hip extensors

1 2 3 4
0
Function of knee extensors

1 2 3 4
Wt: ______
5
When at
least one of
these boxes

is checked,
continue with
SWING
5

Hyperextension of the knee
No
Yes
STABIL
SWING
Unlocks manually only, via a proximally located push

button release system.
Unlocks automatically with simultaneous knee extension and relative

dorsiflexion. Unlocks manually via a proximally located push button release system.
Knee stable in frontal plane

Yes
No
Knee stable in frontal plane

Yes
No
Redressed position of the knee

Valgus 10 * Valgus > 10 Varus
80 kg
Body Weight
80 - 120 kg
> 120 kg
(175 lb)
(175 - 265 lb)
(265 lb)
UTX -STABIL-80
*
UTX- STABIL- 120

Redressed position of the knee

Valgus 10 * Valgus > 10 Varus
Body Weight
100 kg > 100 kg
(220 lb)
(220 lb)
*
80 kg
Body Weight
80 - 120 kg
> 120 kg
(175 lb)
(175 - 265 lb)
(265 lb)
UTX - STABIL- FS
UTX -SWING-80
*
UTX- SWING- 120

Body Weight
100 kg > 100 kg
(220 lb)
(220 lb)
*
UTX - SWING- FS
ADDITIONAL OPTIONS
YES
Thermoplastic (black copoly) thigh and tibial shells for added surface contact. Anterior shells standard.
Medial ankle joint to enhance M-L control of ankle instability.
ADDITIONAL CONERNS
Bones in the leg are capable of carrying body weight. A UTX orthoses is not able to carry the body weight.
Concerns
No or small flexion contracture in the knee (less than 10 degrees).

A knee flexion contracture greater than 10 degrees will load the orthosis excessively.
No or minor spasticity. Spacsticity can lead to excessive forces on the orthosis. When using a UTX -SWING
spasticity can result in a knee joint that will not unlock.
Sufficient cognition. Cognitive problems can hamper the successful application of the SWING type.
Take measurements and fax order: 248-588-4555
Contact Becker to discuss 248-588-7480 E-mail: [email protected]
*UTX orthosis contraindicated. Please contact Becker Orthopedic for alternatives.
Phone:
Fax:
800-521-2192
800-923-2537
9000 SERIES KNEE-ANKLE-FOOT ORTHOSES (9000 KAFO)
Todays Date: _____________________________________________
2.3.9
3495 Sec2.3 9000 KAFO 2/19/05 3:46 PM Page 8
Patient: ___________________________________________________
Facility: ___________________________________________________
Age: ______ Sex: ______ Ht: ______
Street: ____________________________________________________
Diagnosis: ________________________________________________
City: _____________________________ State: _____ Zip:_________
___________________________________________________________
Orthotist: _________________________________________________
Delivery Date: _____________________________________________
Phone Number: ___________________________________________
PO Number: ______________________________________________
ANATOMICAL DATA
Required with
impression
take measurements with leg extended

* Reference line is the floor, bottom of foot, or any
equivalent line perpendicular to the leg.
KNEE ANGLE
At large hyperextension angles (larger than
20 degrees) it is advisable to place P3 and
P4 on the posterior side of the leg.
Figure 1:
Pelotte Carrier Locations
PELOTTE CARRIER P1
LOCATION: 4 CM BELOW PERINEUM
P1
PELOTTE CARRIER P2
P2
LOCATION: 6 CM ABOVE PROXIMAL

EDGE OF PATELLA
Knee Center
Tibial
Plateau
2.3.10
Todays Date: _____________________________________________
P3
Circumferences,
D1, and A-Ps
required with
PELOTTE CARRIER P3
impression
LOCATION: 6 CM BELOW DISTAL
EDGE OF PATELLA
Medial
Malleolus
P4
PELOTTE CARRIER P4
LOCATION: 10 CM ABOVE LATERAL MALLEOLUS
9000 SERIES KNEE-ANKLE-FOOT ORTHOSES (9000 KAFO)
UTX ORTHOSIS MEASUREMENT FORM
Lateral Malleolus
MEDIAL ANKLE JOINT (DZ)
(See Selection Form for more info)
FOOTPLATE (Choose one)
COLOR OF STRAPS
SHOE SIZE
LEFT / RIGHT
Wt: ______
Knee center-reference line*

Tibial plateau-reference line*
Lateral malleolus-reference line*
Medial malleolus-reference line*
Corrected valgus or varus angle
(only with UTX-FS)
Hyperextension angle
Place P3 and P4 posterior
Flexion contracture angle
________ cm
________ cm
________ cm
________ cm
Circumference (C1)
M-L Diameter (ML1)
A-P Diameter (AP1)
Distance (D1) - P1 to reference line*
Comfortpad
Circumference (C2)
M-L Diameter (ML2)
A-P Diameter (AP2)
Comfortpad
Circumference (C3)
M-L Diameter (ML3)
A-P Diameter (AP3)
M-L from Tibial crest to lateral border
Circumference (C4)
M-L Diameter (ML4)
A-P Diameter (AP4)
Is medial ankle joint desired?
M-L of ankle
Preformed thermoplastic footplate
Custom foot cup
Mount to shoe
Stainless steel footplate
None, stirrup only
Beige Black Navy
________________
Left Right
________ cm
________ cm
________ cm
________ cm
Yes No
________ cm
________ cm
________ cm
________ cm
Yes No
________ cm
________ cm
________ cm
________ cm
________ cm
________ cm
________ cm
________ cm
________ cm
Yes No
________ cm

Phone:
Fax:
________
________
Yes No
________
800-521-2192
800-923-2537
3495 Sec2.5 AFO 2/19/05 3:44 PM Page 4
AFO ORTHOMETRY FORM

Todays Date: _____________________________________________
Patient: ___________________________________________________
Facility: ___________________________________________________
Age: ______ Sex: ______ Ht: ______
Street: ____________________________________________________
Diagnosis: ________________________________________________
City: _____________________________ State: _____ Zip:_________
______________________________________________________
Orthotist: _________________________________________________
Delivery Date: _____________________________________________
Phone Number: ___________________________________________
PO Number: ______________________________________________
Wt: ______
ANKLE-FOOT ORTHOSES (AFO)
MEASUREMENTS: Inches Centimeters
Ankle
Varus
Valgus
Flexible
Rigid
Degrees: __________________
Toe Out
Toe In
Medial Plane
Lateral Plane
Degrees: __________________
Heel Height: _______________
2.5.6
Phone:
Fax:
800-521-2192
800-923-2537
3495 Sec2.5 AFO 2/19/05 3:44 PM Page 5
AFO ORTHOMETRY FORM CONTINUED:

Todays Date: _____________________________________________
Patient: ___________________________________________________
Facility: ___________________________________________________
Age: ______ Sex: ______ Ht: ______
Street: ____________________________________________________
Diagnosis: ________________________________________________
City: _____________________________ State: _____ Zip:_________
______________________________________________________
Orthotist: _________________________________________________
Delivery Date: _____________________________________________
Phone Number: ___________________________________________
PO Number: ______________________________________________
LEG: Left Right Bilateral
Wt: ______
MATERIAL: Thermoplastic Metal and Leather
TYPE: DFA Semi-Rigid Rigid TRAFO Floor Reaction PTB Night Splint Healing Brace Bi-Value
Articulating Other: ___________________________
TYPE of FO: UCB SMO Tone Reducing Insert
Metal and Leather Options
Plastic (select one from each column)

Type
Thickness
Location
Flares
Polypropylene
1/8"
Anterior
Proximal
Copolymer
5/32"
Posterior
Medial
Polyethylene
3/16"
Lateral
1/4"
Leather (select one from each column)

Color
Closure
T-Strap
Miscellanous
Black
Hook & Medial Calf Lacer
Beige
Loop
Lateral Leather Gauntlet
Smoked Elk Leather None
SS Footplate
Brown
Strap &
(please provide cast)
White
Buckle
Correct cast to: _____________________
Do not correct cast

Type
Thickness
Location
Aliplast
1/8"
Anterior
Posterior
Med-Density Pelite
5/32"
Footplate
Plantar Surface
Other ______________ 1/4"
Other _________________

Dorsiflexion Assist
Dorsiflexion Plus Assist
Slim Line Double Action
Original Double Action
Standard Action
Size: A (Adult)
Gillette
Gillette Heavy Duty
Camber Axis Hinge
Other __________________
___________________________
C (Child)
Posterior Stops (select type)

655
755 795
None (Free Motion)
C (Child)
Range of Motion

Tamarack
Oklahoma (Polypro)
Size: A (Adult)
B (Youth)
B (Youth)
Stirrup (select type)

Solid
Solid Wide Flange
Split
UCBL
Other __________
Other ____________________________
**Height of AFO: __________________
Plantarflexion _______________ Dorsiflexion _______________

Uprights (select one from each column)
Material
Stainless Steel
Aluminum
Finish
High Buff
Bead Blast
Thermoclad
Black
White
Blue
Size
1/4"x 3/4"
3/16"x 3/4"
1/4"x 5/8"
3/16"x 1/2"
3/16"x 5/8"
1/8"x 1/2"
Thermoplastic Options
Miscellaneous
ST Pad
Dorsal Straps
Loctite all screws
Figure 8
HFH Strap
(Padded Dorsum Strap)
Trim Lines
Met. Heads: _______________________
Sulcus: ____________________________
Full Length: ________________________
Lateral Trimline
Medial Trimline
Phone:
Fax:
Length of Foot
800-521-2192
800-923-2537
2.5.7
3495 Sec2.5 AFO 2/19/05 3:44 PM Page 7
CAD/CAM AFO ORTHOMETRY FORM

Todays Date: _____________________________________________
Patient: ___________________________________________________
Facility: ___________________________________________________
Age: ______ Sex: ______ Ht: ______
Street: ____________________________________________________
Diagnosis: ________________________________________________
City: _____________________________ State: _____ Zip:_________
______________________________________________________
Orthotist: _________________________________________________
Delivery Date: _____________________________________________
Phone Number: ___________________________________________
PO Number: ______________________________________________
AFFECTED SIDE: Left Right
Type
Lengths
Measurements
1
Top of AFO
Mid-Calf
Base-Calf
Narrowest Calf
Apex of Medial Malleolus
Posterior Calcaneus to Apex of First Metatarsal Head
Posterior Calcaneus to Apex of Fifth Metatarsal Head
Base of Fifth Metatarsel to Apex of Fifth Metatarsal Head
Apex of First Metatarsel Head to Apex of Fifth Metatarsal

Head
10
Navicular to Base of Fifth Metatarsal (oblique)
11
Medial Calcaneus to Lateral Calcaneus
12
Medial Malleolus to Lateral Malleolus (oblique)
13
ML at Narrowest Calf
14
ML at Base Calf
15
ML at Mid-Calf
16
ML at Top of AFO
17
AP at Heel
Value
SHOE SIZE: _________________
Alignment Information
Ankle Mortise
(If unmarked, 0 will be used)
Dorsiflexion _______________
Plantarflexion ______________
Hindfoot
Inversion _______________
Eversion _______________
Forefoot
Supination _______________
Pronation _______________
ADduction _______________
ABduction _______________
Toe
(If unmarked, 7 out will be used)
ML diameters
of foot
In _______________
Out _______________
Additional Information
Arch
ML diameters
of leg
AP diameters
High Mid Low None

Navicular Relief
Proximal Flare
( __________" standard)
Custom Proximal Flare
( __________" specify depth)
Height from
bottom of
foot to:
MEASUREMENTS: Inches Centimeters Millimeters
Wt: ______
Tibial Varum
Circumference 18
at:
Offset from posterior calcaneus

to center of desired posteriorproximal trimline:
________________
Narrowest Calf
19
Base Calf
20
Mid-Calf
21
Top of AFO
Height from floor to point

where varum becomes
noticeable: _______________
Phone:
Fax:
800-521-2192
800-923-2537
2.5.9
3495 Sec2.5 AFO 2/19/05 3:44 PM Page 8
CAD/CAM AFO ORTHOMETRY FORM CONTINUED:

Todays Date: _____________________________________________
Patient: ___________________________________________________
Facility: ___________________________________________________
Age: ______ Sex: ______ Ht: ______
Street: ____________________________________________________
Diagnosis: ________________________________________________
City: _____________________________ State: _____ Zip:_________
______________________________________________________
Orthotist: _________________________________________________
Delivery Date: _____________________________________________
Phone Number: ___________________________________________
PO Number: ______________________________________________
Wt: ______
2.5.10
Phone:
Fax:
800-521-2192
800-923-2537
3495 Sec2.5 AFO 2/19/05 3:44 PM Page 9
CAD/CAM AFO ORTHOMETRY FORM CONTINUED:

Todays Date: _____________________________________________
Patient: ___________________________________________________
Facility: ___________________________________________________
Age: ______ Sex: ______ Ht: ______
Street: ____________________________________________________
Diagnosis: ________________________________________________
City: _____________________________ State: _____ Zip:_________
______________________________________________________
Orthotist: _________________________________________________
Delivery Date: _____________________________________________
Phone Number: ___________________________________________
PO Number: ______________________________________________
Plastic
Thickness
Polypropylene
Copolymer
Polyethylene
1/8"
3/16"
1/4"
Wt: ______
Other: ___________
Options check the choice(s) and add any notes in Special Instructions
Type
Thickness
Location
Aliplast
1/8"
Anterior
Posterior
Med-Density Pelite
5/32"
Footplate
Plantar Surface
Other ______________ 1/4"
Other _________________
Tamarack
Oklahoma (Polypro)
Size: A (Adult)
B (Youth)
Posterior Stops (select type)

655
755 795 Other ____________________________
None (Free Motion)
**Height of AFO: __________________
Miscellaneous
ST Pad
Dorsal Straps
Loctite all screws
Figure 8
HFH Strap
(Padded Dorsum Strap)
Gillette
Gillette Heavy Duty
Camber Axis Hinge
Other __________________
___________________________
C (Child)
Trimlines
Solid Ankle:
Solid (at Malleolar Apex)
Rigid (1/2" Posterior to Malleolar Apex)
Posterior Leaf Spring (Dorsiflexion Assist)
Footplate:
Full Sulcus
(Draw trimlines as necessary)
Other: _______________________________
Other: __________________________________________________
Special Instructions:
Shipping Instructions
UPS Next Day Air
UPS Ground
UPS 2nd Day Air
UPS 3 Day Select
Phone:
Fax:
Other: _________________________
800-521-2192
800-923-2537
2.5.11
Cranial Remolding Orthosis Order Form

Note: A completed order form is required before the order can be processed.
ORTHOTIST INFORMATION
Shipping Address: __________________________ P.O. #: ______________________________________
______________________________________ Date Requested: ______________________________
______________________________________ Phone: ______________________________________
City: ________________ State: ___ Zip: ______ Fax: _______________________________________
Turnaround time is 4 business days from receipt of scan and completed order form.
For best results, the patient should be fit within two weeks from the date of the scan/cast.
PATIENT INFORMATION
Patient Name: ______________________Date of Birth: ___________Date of Scan/Cast: ______________
Diagnosis:
Plagiocephaly
Brachycephaly
Other______________________
SCAN/CAST INFORMATION
Required Landmarks: Outline of ears, brow line marked on both temples, center of nose marked on forehead
Scan Impression: Unmodified Scan/Cast
Modified Scan/Cast
Description of Cranial Form (please indicate all applicable conditions):
FLATTENING
Left
Bilateral
Right
N/A
Occipital Area
Parietal Area
Ear Anterior Shift

Frontal Bossing
Elevated Cranial Height
DESCRIPTION OF DEFORMITY
Left
Right
Posterior
N/A
CRANIAL /UPPER EXTREMITY ORTHOSES
Facility Name: ____________________________ Orthotist Name: ______________________________
Please completely fill out the order form including all required measurements and information.
Page 1 of 2
Phone:
Fax:
800-521-2192
800-923-2537
2.7.3
REQUIRED MEASUREMENTS
Take measurements at a level just above the top of the ears and the brow line over stockinette.
Order will not be processed without required measurements.
FOR INTERNAL USE ONLY
ORTHOTIST
UNMODIFIED MOLD
MODIFIED MOLD
Circumference: _____cm
Cranial Length: _____cm
Cranial Width: _____ cm
Cranial Width: _____cm
Cranial Width: _____cm
Build-up added
Right Anterior
Left Anterior
Right Posterior
Left Posterior
ORTHOSIS INFORMATION
Side Opening:
Left
Right
Attach Chafe:
Anterior to slot
Posterior to slot
Send do not attach
Transfer Paper Design: ________________________________
Positive Image Transfer: ________________________________
Liner Thickness & Density
Copolymer Shell
Medium Soft
Medium
Soft
SPECIAL INSTRUCTIONS
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
SHIPPING INSTRUCTIONS
UPS Ground
UPS 2ND Day Air
UPS Next Day Air
Other: _____________________
FOR INTERNAL USE

Order Number: _________________________
Approved By: ______________________
Please completely fill out the order form including all required measurements and information.
Page 2 of 2
REV 03/11
2.7.3A
Phone:
Fax:
800-521-2192
800-923-2537
3495 Sec2.7 UpperExtrem 2/19/05 3:41 PM Page 8
WHO ORTHOMETRY FORM

Todays Date: _____________________________________________
Patient: ___________________________________________________
Facility: ___________________________________________________
Age: ______ Sex: ______ Ht: ______
Street: ____________________________________________________
Diagnosis: ________________________________________________
City: _____________________________ State: _____ Zip:_________
______________________________________________________
Orthotist: _________________________________________________
Delivery Date: _____________________________________________
Phone Number: ___________________________________________
PO Number: ______________________________________________
MODEL: U-16 U-17 U-18
SIDE: Left Right
Wt: ______
2.7.10
Phone:
Fax:
800-521-2192
800-923-2537

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3495 Sec2.

1 HKAFO 2/19/05 3:48 PM Page 2

HIP-KNEE-ANKLE-FOOT ORTHOSES (HKAFO)

KAFO/HKAFO ORTHOMETRY FORM:

Age: ______ Sex: ______ Ht: ______

City: _____________________________ State: _____ Zip:_________

Delivery Date: _____________________________________________

Phone Number: ___________________________________________

MEASUREMENTS: Inches Centimeters

3495 Sec2.1 HKAFO 2/19/05 3:48 PM Page 3

KAFO/HKAFO ORTHOMETRY FORM CONTINUED:

Age: ______ Sex: ______ Ht: ______

City: _____________________________ State: _____ Zip:_________

Delivery Date: _____________________________________________

Phone Number: ___________________________________________

MATERIAL: Thermoplastic Metal and Leather

TYPE: KAFO HKAFO

Metal and Leather Options

Plastic (select one from each column)

Leather (select one from each column)

Correct cast to: _____________________

Do not correct cast

Liner (select one from each column)

Ankle Joints (select type)

Stirrup (select type)

Plantarflexion _______________ Dorsiflexion _______________

Hip Joint Options

Knee Joint Options

Knee Joints (select one from each column)

Please see catalog section 4 for model numbers

3/16"x 3/4" High Buff

Lever Lock (Bail) G-Knee (9003)

Model Number: _________________

3/16"x 1/2" Black

HIP-KNEE-ANKLE-FOOT ORTHOSES (HKAFO)

LEG: Left Right Bilateral

3495 Sec2.1 HKAFO 2/19/05 3:48 PM Page 5

RGO ORTHOMETRY FORM

Age: ______ Sex: ______ Ht: ______

City: _____________________________ State: _____ Zip:_________

Delivery Date: _____________________________________________

Phone Number: ___________________________________________

328 Iso-Metric Pelvic section only

329 Bio-Metric Pelvic section only

328-K Iso-Metric RGO with KAFOs

329-K Bio-Metric RGO with KAFOs

328-A Iso-Metric with AFOs

329-A Bio-Metric with AFOs

Plastic (Kydex): Ivory

Please Complete Entire Orthometry Form For Best Fit

HIP-KNEE-ANKLE-FOOT ORTHOSES (HKAFO)

3495 Sec2.3 9000 KAFO 2/19/05 3:46 PM Page 7

UTX ORTHOSIS SELECTION PROTOCOL FORM

Age: ______ Sex: ______ Ht: ______

City: _____________________________ State: _____ Zip:_________

Delivery Date: _____________________________________________

Phone Number: ___________________________________________

Function of hip extensors

Function of knee extensors

Age: Sex: Ht: __

City: ___________________________ State: _ Zip:_______

Age: Sex: Ht: __

City: ___________________________ State: _ Zip:_______

Plantarflexion _ Dorsiflexion _

Age: Sex: Ht: __

City: ___________________________ State: _ Zip:_______

Age: Sex: Ht: __

City: ___________________________ State: _ Zip:_______

Age: Sex: Ht: __

City: ___________________________ State: _ Zip:_______

Age: Sex: Ht: __

City: ___________________________ State: _ Zip:_______

Age: Sex: Ht: __

City: ___________________________ State: _ Zip:_______

Plantarflexion _ Dorsiflexion _

Age: Sex: Ht: __

City: ___________________________ State: _ Zip:_______