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Shoes
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Haflinger
Dr. Comfort
DR. Zen
Spira
Naot
Merrell
Dansko
Finn Comfort
Earth
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KEEN
Aetrex
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P.W.Minor
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SOLE SENSATIONS FOOTWEAR&
FOOT PHYSICIANS LABORATORIES

CLIENT / CUSTOMER ASSESSMENT FORM
Printable Version click here.

By Dr. Ray Stidd
Since 1962

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  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code:

Social Security Number (Optional):  

Medicare Number (Optional):  

Date of Birth:  Month  January Feburary March April May June July August September October November December  Day  1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  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! 

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