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Prescriptions
Please fill out the prescription form below.
Footwear Prescription
Client Name
*
Notes / Diagnosis
Foot Type
Neutral
Pronated
Supinated
Foot Complications
Diabetes
Hammer Toes
Bunions
Neuropathy
Edema
Arthritis
Shoe Modifications?
Yes
No
Shoe to Accommodate Orthotics?
Yes
No
Shoe Category
Neutral
Stability
Shoe Style Required
Casual/Dress
Indoor
Walking
Running
Velcro Fastening/Quick Laces
Minimal Seems
Extra Width
Shoe Criteria
Forefoot Rocker
Flexible
Stiff
Torsional Rigidity
Flexible
Stiff
Cushioning
Low
Maximal
Heel Drop (mm)
0
0-4
4-8
8+
Detail
Notes
Medical Practitioner