Orthotic Prescription Survey
Please complete this survey to assist in the clinical assessment and prescription of orthotic devices.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email Address
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for Orthotic Assessment
*
Foot pain or discomfort
Gait abnormalities
Injury recovery
Prevention of further injury
Other
Clinical Diagnosis (if applicable)
Please rate your current level of pain or discomfort related to your condition.
*
No pain
0
1
2
3
4
5
6
7
8
9
Severe pain
10
0 is No pain, 10 is Severe pain
Functional Limitations Assessment
*
Rows
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
Walking short distances
1
2
3
4
Standing for prolonged periods
5
6
7
8
Climbing stairs
9
10
11
12
Participating in sports
13
14
15
16
Have you previously used orthotic devices?
*
Yes
No
If yes, please describe the type and your experience with previous orthotic devices.
What are your primary goals for orthotic intervention? (Select all that apply)
*
Pain relief
Improved mobility
Injury prevention
Support for daily activities
Other
Additional Comments or Relevant Medical History
Submit Survey
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