Biomechanical Evaluation & Orthotic Prescription Step 1 of 2 50% Pt File - Surname, Name*PodiatristMegan MaddocksDate of Appt* Date Format: DD dot MM dot YYYY Start Time* HH : MM End Time* HH : MM Location*Parkmore RoomsWoodmead RoomsHouse CallIntercare Day Hospital RivoniaWhich Appointment?*First AppointmentFollow Up AppointmentFirst Physical Appointment after Initial Telehealth ConsultationCO / History / ChangesDate Of Birth* DD MM YYYY Current AgeSex*MaleFemaleHeight (cm)*Weight (kg)*Shoes (EU)*ON PALPATIONTenderness*R onlyL onlyBoth sides equallyR > LL > RL & R differentnoneUntitled Achilles Tendon above insertion Achilles Tendon at insertion Post Tib Tendon at insertion Post Tib Tendon along course of tendon Post Tib Tendon muscle belly Ankle Gutter Medial Ankle Gutter Lateral Plantar Fascia proximal portion (heel) Plantar Fascia mid portion (arch) Plantar Fascia distal portion (MTPJ area) STANDINGHead PositionNo misalignmentTilted towards R shoulderTilted towards L shoulderComputer posture / kyphosis Instructions Rest and elevate for 24-48 hours Keep dressing on and dry for 24 hours Keep dressing on and dry for 48 hours Keep dressing on and dry for 72 hours Keep dressing on and dry until 1st dressing appt Avoid sport and activity for 2 weeks Avoid anti-inflammatory medications Home to sleep Painkillers as soon as LA wears off Consent for Medici Patient to download Medici for follow ups Instructions to be given over Medici Other How were instructions given? Verbal Written Info Sheet Medici App Other instructionsPrescriptionFormal PrescriptionPanadononePrescription detailsORTHOTIC PRESCRIPTIONMaterialLocal BiSport (50/55)-(40/45)Local BiPlus (40/45)-(30/35)Local BiComfort (40/45)-(20/25)Local Multicolour (40/45)Local Stoney (White) (50/55)Local Stoney (Black) (50/55)Local Stability (40/45)Local Relax (30/35)Local Relax Plus (20/25)Double Black (40/45)Granite (70/75)Pink Speckle (40/45)Local Stratos 5 (40/45)Local Reverse (40/45)Arch HeightSubstantial / very highModerateLowMedial HF WSubstantial / very high (8-12)Moderate (6-7)Low (<6)Heel BorderVery high (>30mm)High (25-30mm)Moderate (18-24mm)Low (11-17mm)Very Low (10mm)NoneHeel RaiseForefoot Met Bar PMP 1st Ray Cut Out 5th Ray Cut Out Cluffy Wedge Kinetic Wedge Toe Offloads CoverEVAFirenze / VinylVL3PoronSpencoMonoPig SkinSuede / LeatherVery thin (fun)HD (No Cover)Untitled First Choice Second Choice 1 2 Third Choice 3 4 5 OtherGoing ahead with them now?YesNoConsent Signed?YesNoPlan going forward Shoes First Physio / Bio / Other practitioner Padding & Strapping for a few weeks Next AppointmentFollow ups over MediciFace to Face AppointmentHow many days from procedure?1 day2 days3 daysUntitledFirst ChoiceSecond ChoiceThird Choice
