Sole
Sensations

For over
42 years!
Inserts 


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Shoes
BIRKENSTOCK
Haflinger
Dr. Comfort
DR. Zen
Spira
Naot
Merrell
Dansko
Finn Comfort
Earth
Beautifeel
KEEN
Aetrex
Apex
P.W.Minor
Xsensible
Birki's
Alpro
Diabetic

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Dr. Ray Stidd



Expert Staff!

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SOLE SENSATIONS FOOTWEAR&
FOOT PHYSICIANS LABORATORIES

CLIENT / CUSTOMER ASSESSMENT FORM
Printable Version click here.

By Dr. Ray Stidd
Since 1962
Thanks for Coming!   Dr. Ray Stidd

FREE Questionaire: Please let me see if I can help!
*Please read each question and answer as to current symptoms & conditions.

Privacy Statement

We do not share any information with 3rd parties.

Your Name:

Your Email Address:

Your Phone Number:

Address:

City
  State  Zip Code:

Social Security Number (Optional):  

Medicare Number (Optional):  

Date of Birth:  Month   Day   Year   

Gender?
Female    Male

1. Brief Description of Current Foot Problems:

2. Current Other Medical Conditions for which you are under treatment:

3. Brief Description of Past Treatment for foot problems:

4. Have you worn orthotics in the past?
Yes    No

5. Are you currently wearing orthotics?
Yes    No

6. Are (were) your orthotics of rigid?
Yes    No

7. Are (were) your orthotics full-sole?
Yes    No

8. Are (were) your orthotics comfortable to wear?
Yes    No

9. Do (did) you encounter difficulty in finding comfortable
shoes that fit well with your orthotics?

Yes    No

10. Would you like our professional assistance in
selecting the optimum type of footwear for your
current condition, foot-type, and orthotic-type?

Yes    No

11. What areas that are most uncomfortable/painful on your
foot, ankle, knee, thigh or back?

18. Any additional comments you wish to list regarding the
professional orthotics/appliance to be made for you.

Please 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

"YOUR ONE-STOP DESTINATION, EVERYTHING FOR THE FOOT"

THE MOST UNIQUE OFFERING IN FOOT HEALTH NEEDS!

1. The perfect orthotic for every foot deformity/need!
2. The perfect shoe for your foot & orthotic!
3. ANSWERS BY: America's foremost physician authority on footgear! 


Home  Foot Pain  Orthotics  Laboratory  Foot-Aid Products  Shoes  Foot Pathologies
About Us  Contact Us  Directions

Sole Sensations
115 E. Second St.
Bloomington,IN, 47401
Phone: (812) 331-1962
Fax: (812) 332-1949
Store@solesensations.com


Copyright © 2008 Sole Sensations. All rights reserved.

Foot
Physicians
Laboratories

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Orthotics


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Personalized
Orthotic Evaluation!
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The Pain
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Inserts
May Be Prescribed
If You Have
Discomfort From
Sore Feet
Sore Ankles
Sore Legs
Sore Back
Tired Feet
Tired Ankles
Tired Legs
Fatigue
Stress
Diabetes ?????
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For Help!

Foot Physicians Laboratory (812) 331-1962
Foot Physicians Laboratory (812) 331-1962
Foot Physicians Laboratory (812) 331-1962
Foot Physicians Laboratory (812) 331-1962
Foot Physicians Laboratory (812) 331-1962
Foot Physicians Laboratory (812) 331-1962
Foot Physicians Laboratory (812) 331-1962
Foot Physicians Laboratory (812) 331-1962

Solutions
To Stop
The Pain
Click Here Now!

Get Your Free
Personalized
Pain Evaluation!
Click Here Now!