Assessment

Account Information

Account Name: Clinic Email:

Patient Information

First Name:   Last Name:
Occupation:
Age:   Gender:
Height (ft.):   (in.):   Weight (lbs.):
Shoe Style 1: Shoe Style 2: Width: Shoe Size:
Notes:

Chief complaint of pain/diagnosis

Gait Evaluation

Left Right
Heel Strike:
Midstance:
Toe Off:
Heel Lift:
Gait Pattern:

Biomechanical Examination Findings

Left Right
Arch Height-Off Weight Bearing:
Arch Height-Weight Bearing:
Subtalar Joint Range of Motion:
1st Ray Motion:
1st Ray Position:
Hallux Dorsiflexion:
HAV:
LLD (short by - millimetres):
Ankle Dorsiflexion: Left: Right:
Knee Position:

Clinician's Measurements

Left Right
Rearfoot:
Forefoot:
Tibial Angle:
Relaxed Calcaneal Stance:

Shoe Findings

Distal
Forefoot
Midfoot
Rearfoot
Distal
Forefoot
Midfoot
Rearfoot
Footwear Upper:
Other:
Footwear Upper:
Other:

Callous Formation











Other:

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