Custom to Cast Upper Extremity Orthotics Measurement Form

(SEWHO/SO/EWHO/EO/WHO/HO )
Clinic Location: __________________________ Practitioner: _________________________
Name of the Patient: ________________________________________ Age & Gender: ________
Height : ________ Weight : _______ Kgs Bilateral Right Left
Fabrication Mode: Standard Priority Urgent Work Order No:
TAT TAT TAT Date:
Check box if Patient is a current or previous brace wearer
Product Specifications
Diagnosis Prescription
Diagnosis / Type of UE Injury:

Upper Extremity Orthosis Type Thermoplastic Type & Thickness

Shoulder Elbow Wrist Hand Orthosis (SEWHO) AIRPLANE Type _____________ 3mm / 4mm / 5 mm
Shoulder Orthosis (SO) Liner / Padding Type & Thickness
Elbow Wrist Hand Orthosis (EWHO) _______________ 3mm / 4mm / 5 mm
Elbow Orthosis (EO) Static / Positional / Night Resting Soft Pad Firm/ Pelite Pad
Elbow Orthosis (EO) Dynamic with Turnbuckle Other / Specify:
Elbow Orthosis (EO) Dynamic with Elbow Hinged Joint Finishing Instructions
Wrist Hand Orthosis (WHO) Static / Positional / Night Resting Built In Relief (Surgery Relief)
Hand Orthosis (HO) Static / Positional / Night Resting Foam Pads (Over bony areas only)
Upper Arm / Humeral Fracture Orthosis Complete Inner Padding
Forearm Fracture Orthosis Ventillation holes / cutouts
Other / Please Specify Flare Out Edges
Upper Extremity Orthosis - Designs Straps
Bi-Valve - Open with Tongue 1" 1.5" 2"
Anterior Overlap with Tongue (Single Opening) Plastic Webbi
Posterior Orthosis (with Straps & Chafe ) - Standard Arm Sleeve
Other / Specify: Qty: _____ Small / Med / LRG / X-Large
Clinical Advisory for C-fab by Clinician (If any)
In this section a clinician needs to mention anything that he / she wants to describe about the Device

Orthotic Parts / componentry to be used (To be filled by Clinican / C-fab)

Part Code Name of the Part / Component Component type Status

C-Fab Advisroy and Remarks for Clinician (If any)

Custom to Cast Upper Extremity Orthotics Measurement Form
(SEWHO/SO/EWHO/EO/WHO/HO )
Measurements (in Cms) - To be filled by Clinican

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