Biomechanical Foot Assessment
Please complete this form to help us evaluate your foot biomechanics for diagnosis and treatment planning.
Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Reason for Assessment
*
Do you experience foot or lower limb pain?
*
No pain
Occasional pain
Frequent pain
Constant pain
Please rate your average pain level
*
No pain
0
1
2
3
4
5
6
7
8
9
Severe pain
10
0 is No pain, 10 is Severe pain
Foot Posture and Function Assessment
*
Rows
Left Foot
Right Foot
Arch Type (High, Normal, Flat)
1
2
Heel Alignment (Neutral, Varus, Valgus)
3
4
Forefoot Alignment (Neutral, Abducted, Adducted)
5
6
Toe Deformities (None, Hallux Valgus, Hammer Toe, Other)
7
8
Gait Observation
*
Normal gait
Overpronation
Supination
Limp
Other (please specify)
Range of Motion (ROM) Assessment
Rows
Left Foot
Right Foot
Ankle Dorsiflexion (degrees)
Ankle Plantarflexion (degrees)
Big Toe Dorsiflexion (degrees)
Usual Footwear Type
Athletic shoes
Sandals
Dress shoes
Boots
Other
Activity Level
Sedentary
Lightly active
Moderately active
Very active
Submit Assessment
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