Metal AFO/KAFO

8647 W. 95th Street • Hickory Hills, IL 60457 • ( T ) 866.914.AOPS • ( T ) 708.237.4099 • ( F) 708.598.2857

(2677)

PA T I E N T I N F OR MAT I ON

Today’s Date: Due Date: Account #: P.O. #:

Patient Name: Facility: Practitioner:

Patient ID #: Bill To: Ship To:

Sex: ■ M ■ F Affected Side: ■ Left ■ Right ■ Bilateral

Age: Height: Weight: ■ Ground ■ 2 Day ■ Next Day

ORDER DESCRIPTION AFO KAFO

1 Device: ■ N/A Sidebars: Knee Joints Part #:

■ Single ■ Aluminum Leather Color:
■ Metal AFO ■ Metal KAFO
■ Double ■ Stainless Steel
■ Shoe Transfer Knee Straps:
Sidebar Size:
Tracing Reversed and Device Ready ■ Full Knee Cap ■ Varus Control
to Be Fabricated: Joint Type: ■ Valgus Control ■ Intrapatellar
■ Yes ■ No ■ Double Action ■ Dorsi Assisi ■ Suprapatellar ■ None
■ Limited Motion ■ Free
Finish:
2 Shoe(s): ■ N/A Stirrup: ■ Sandblasted ■ Polished
Shoe Size:
■ Standard ■ Wide Tongue
Ball Retainers:
■ Split ■ Long Tongue
Model #: ■ Yes ■ No
■ Reinforced ■ NYU/UCB
Color:
T-Strap: Notes:
Rocker Sole:
■ Lateral ■ Medial
■ Toe Only ■ Heel & Toe
Finishing:
Order Status:
■ Exterior Steel Shank
■ One Shoe Sent
■ Velcro to Shoes
■ Pair of Shoes Sent
■ Shoes Already on Order Shoe Modifications:
■ Shoes Need to be Ordered

ADDI TI ONAL INSTRUCTIONS CIRCMFS M•L LENGTHS ■ Inches

DIAMETERS ■ Centimeters
WAIST LINE
A
PELVIC LINE
B
TROCHANTER
C
ISCHIAL TUBEROSITY
D
30M M

KNEE AXIS
F
FIB NECK
G

ANKLE
AXIS
H

2006-F-1