*Please read each question and answer as to current symptoms & conditions.
1. (Name) ________________________________________________________
2. (Address) ________________________________________________________
(City)________________________ (State) _____ (Zip Code) __________
3. (Phone) _______________________________________
4. (Social Security #) ______________________________
5. (Medicare #, if applicable) ___________________________________________
6. (Date of Birth) ____________________ (circle gender) MALE FEMALE
7. (Brief Description of Current Foot Problems) ____________________________
____________________________________________________________________
8. (List of Current Other Medical Conditions for which you are under treatment) _
____________________________________________________________________
____________________________________________________________________
9. (Brief Description of Past Treatment for foot problems) ____________________
____________________________________________________________________
____________________________________________________________________
10. Have you worn orthotics in the past ? (circle) YES NO
11. Are you currently wearing orthotics ? (circle) YES NO
12. Are (were) your orthotics of rigid ? (circle) YES NO
13. Are (were) your orthotics full-sole ? (circle) YES NO
14. Are (were) your orthotics comfortable to wear ? (circle) YES NO
15. Do (did) you encounter difficulty in finding comfortable
shoes that fit well with your orthotics? (circle) YES NO
16. Would you like our professional assistance in
selecting the optimum type of footwear for your
current condition, foot-type, and orthotic-type ? (circle) YES NO
17. Refer to the anatomical foot/ankle picture(s) below and mark (X) at the areas that are most uncomfortable/painful on your foot. (X-1, most painful; X-2, less painful).
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18. Any additional comments you wish to list regarding the professional orthotics/appliance to
be made for you. ___________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
READ & ACKNOWLEDGE:
The laboratory fabricating your orthotic (appliance) makes no guarantee as to treatment or cure of any medical condition you now have or may have either now or in the future.
YES
NO