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CLINIC PORTAL
Home
About
Services
Contact
CLINIC PORTAL
PDE AFO
PDE AFO
Step
1
of
5
20%
Order Details
Clinician
*
Contact Phone
Contact Email
*
Due Date
Standard Turn Around
Rush Order
Date
MM slash DD slash YYYY
Patient Details
Patient name/ID
*
Patient Weight (kg)
*
Patient Height (cm)
*
Activity Level
Non-Ambulatory
Low Activity
Medium Activity
High Activity
Model Details
Side
*
Left
Right
Bilateral
Model Details
*
I am providing a MODIFIED scan
I am providing an UNMODIFIED scan
I am posting a negative cast
I am posting a modified plaster model
Scan File
Accepted file types: stl, cvx, o01, obj, ply, vsrf, Max. file size: 2 MB.
We will accept scans in the following formats: .stl .cvx .o01 .obj .vsrf .ply
I will be posting/supplying components
No
Yes
Manufacturing Details
PDE Strut Category
*
Cat 1
Cat 2
Cat 3
Cat 4
Cat 5
Cat 6
Cat 7
PDE Strut Length
*
Determine from Model
200mm
250mm
300mm
Cuff Detail
*
Hinged Anterior Section
Anterior Section with BOA dial
Encapsulate Dorsum of Foot with Plastic
No
Yes
Trimline Details
Anterior Cuff Height
*
Below Tibial Tuberosity
At Mid Patellar Tendon
Mid Patellar
Carbon Boot Height - Medial Side
*
Low Profile
Medium Profile (standard)
High Profile (above Malleoli)
Carbon Boot Height - Lateral Side
*
Low Profile
Medium Profile (standard)
High Profile (above Malleoli)
Encapsulate Met Heads (plastic only)
*
None
First MH Only
Fifth MH only
Both First and Fifth MH
Foot Length (cm)
*
measured from back of heel
Proximal Trim Height (cm)
*
measured from base of heel
Cosmetic Detail
Cosmetic Finish
Standard Carbon Finish
Fabric Covering
Aluminium Finish
Vinyl Wrap
Vinyl Colour
First Choice
Second Choice
Third Choice
Padding Colour
Black
White
Blue
Pink
Subject to availability
Strap Colour
*
White
Black
Yellow
Blue
Green
Red
Purple
Pink
Strapping
Ankle Strap
*
None
25mm Strap
Pronation Control Strap
Suppination Control Strap
Forefoot Strap
*
None
One
Padding
Malleoli Padding
*
None
Medial
Lateral
Both
Plantar Padding
*
None
Foam
Leather
Additional Spot Padding
No
Yes
3mm EVA Foam
Spot Pad
Soling Details
Heel Raise
None
Heel Stabiliser Only
Heel Raise to MH
Full Length Raise
Raise Height Under Heel (cm)
*
Raise Height Under MH (cm)
*
Cast Corrections
Corrections Are:
Identical Left and Right
Different Left and Right
Are the cast corrections the same on each side?
Anglular Cast Corrections
Please carefully review your selection
Left Side Anglular Cast Corrections
Please carefully review your selection
Corrected Side
Left
Right
Ankle Angle
*
Neutral/Plantigrade (SVA 5deg)
As Cast/Scanned
Dorsiflexion
Plantarflexion
Ankle Angle (degrees)
Calcaneal Angle
*
Neutral
As Cast/Scanned
Eversion
Inversion
Calcaneal Angle (degrees)
Toe Spring Angle
*
Standard
None
Other
Toe Spring Angle (degrees)
Shoe Pitch (mm)
Additional to other angular corrections
Forefoot Corrections
Left Side Forefoot Corrections
Offset
*
Neutral
As Cast/Scanned
Abducted
Adducted
Forefoot Offset (degrees)
Rotation
*
Neutral
As Cast/Scanned
Inverted
Everted
Forefoot Rotation (degrees)
Trimline Circ. (mm)
Supra Malleolar M-L (mm)
Malleolar M-L (mm)
MetHead M-L (mm)
Trim Height (mm)
Trim Length (mm)
Specific Offloading and Additional Information
Right Side Angular Cast Corrections
The Other Side
2nd Corrected Side
Left
Right
2nd Ankle Angle
*
Neutral/Plantigrade (SVA 5deg)
As Cast/Scanned
Dorsiflexion
Plantarflexion
2nd Ankle Angle (degrees)
2nd Calcaneal Angle
*
Neutral
As Cast/Scanned
Eversion
Inversion
2nd Calcaneal Angle (degrees)
2nd Toe Spring Angle
*
Standard
None
Other
2nd Toe Spring Angle (degrees)
Shoe Pitch (mm)
Additional to other angular corrections
Right Side Forefoot Corrections
2nd Offset
*
Neutral
As Cast/Scanned
Abducted
Adducted
2nd Forefoot Offset (degrees)
2nd Rotation
*
Neutral
As Cast/Scanned
Inverted
Everted
2nd Forefoot Rotation (degrees)
2nd Specific Offloading and Additional Information
Trimline Circ. (mm)
Supra Malleolar M-L (mm)
Malleolar M-L (mm)
MetHead M-L (mm)
Trim Height (mm)
Trim Length (mm)
Additional Information
