Name Weight lb kg
Sex： (M) (F) Age:
ActivIties:
Footwear Type

Leather Shoes Sport Shoes
Hight Heel Shoes inch cm
Shoe size US EUR UK
Pre-fab.insole
Fabrication
Repair
2nd Pair Order
Previous Working No: 		Enclosed with
Shoes
Insole
Cast
Foottype
Planns Nornal
Cavus    Equinus
Other
Flexible Normal Rigid
Foot flexibility
Leg length Discrepancy L R
Diagnosis:
For Official Used Only
Workong Number:
完成产品日期 日 月 年
免费 样板
其它 金额
Prescriber's info:
Name: Clinic:
Phone:
ⅠCHOOSE Standard Design（Please refer to product catalogue）

A)Functional---Dress Shoe Series
CODE NO:
B)Semi-flexible---sport Shoe Series
CODE NO:
C)Accommodative---Shoes with enough space
CODE NO:
D)For Children
CODE NO:
Ⅱ  
Choose the design part by part
PART1 Shell
●SHAPE
Standard UCBL
Toe-in Cobra
Others
●RIGIDITY
Extra-rigid(4mm pp)
Rigid(3mm pp)
Semi-Rigid(2mm pp+Lengthened Heel Seat+arch fill)
Semi-flexible(2mm pp+arch fill)
Soft(4mm pp)(40°EVA shell)
Lab Evaluation

PART2 Top Cover
●Top Layer
wMaterial
 Length
LEATHER
Vinyl
Others		 3/4
Sulcus
Full length
 
●Middle Layer
Material Tickness Length
poron 3mm Sulcus
EVA 1mm Full length
Carbosan Foam Other
mm 		 
PART3
Arch fill on Plaster Cast
                    (Measured from arch apex)
No filling
Minimal filling (2mm thickness)
Moderate filling (2mm thickness)
filling L) mm R) mm
L) mm R) mm
Symmetrical arch height

PART4 Measurements
A Non-weight bearing position
●Rear foot
Varus Valgus
      L °       R °
●Forefoot
Varus Valgus
      L °       R °
B Posting Instructions
Ⅰ●Rear foot
Medial 外Lateral
Shell(Max:3°) L °R °
Eva (Max:5°)         L °R °
XEva No Heel Seal
●Forefoot
Medial 外Lateral
Shell(Max:5°) 左/L °右/R °
Eva (Max:5°)         左/L °右/R °
Ⅱ Neutral
Ⅲ Skives L R
Ⅳ Lab Evaluation
PART5 Shell Modifications
ⅠHeel Cup Depth
No Heel Cup        Shallow (10mm)
Regular (15mm) Deep (20mm)
Others mm
Ⅱ 1st Met cut-out        filled with Poron
Ⅲ Orthotic Width
Narrow(for high heel shoes)
Regular(for dress shoes)
Wide (follow the cast shape for sport shoes)
Ⅳ  Medial Flange   with sofe padding
              
 
PART6 Addaitions
ⅠHeel Cup Depth
1 Heel lift    mm L R
            
2 Heel pad                  L R
          
3 Heel hole                 L R
          
4 Horse shoe spur       L R
          
5 Arch fill                     L R
          
6 Metatarsal pad ( thick thin)
                                          L R
     
7 Metatarsal bar          L R
          
8 Neuroma pad           L R
          
9 Morton's extension   L R
          
10 Reverse Morton's extension                                                              L R
          
Repair Notes
Download the forms here:
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