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CLINIC PORTAL
Home
About
Services
Contact
CLINIC PORTAL
Thermoplastic KAFO
Thermoplastic KAFO
Step
1
of
4
25%
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
What Components will you send?
Manufacturing Details
Plastic Type
Polypropylene
CoPolymer
Plastic Thickness
3mm
4mm
5mm
Thigh Shell Design
*
Posterior Shell
Anterior Shell
Calf Shell Design
*
Posterior Only
Anterior Only
Posterior with Bi-Valve Anterior section
Foot Section Design
Full Length
Sulcus Length
3/4 Length
Stirrup/Heel Only
Knee Joint
Streifeneder Artikon Knee Joint
Streifeneder Artikon Posterior Offset Knee Joint
Other
Which Knee Joint?
Ankle Joint
None
Streifeneder Artikon Double Action
Other
Which Ankle Joint?
Additional Components Required?
Trimline Details
Encapsulate Met Heads
*
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
Transfer Paper
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
Thigh Straps
*
None
2 Straps
3 Straps
Shin/Calf Strap
*
One
None
Ankle Strap
*
None
25mm Strap
Pronation Control Strap
Suppination Control Strap
Padding
Thigh Shell Lining
*
None
3mm EVA
Comfortex
Calf Shell Lining
*
None
3mm EVA
Comfortex
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)
*
Post Heel?
None
Post Medially
Post Laterally
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
Corrected Side
Left
Right
Knee Angle
*
Neutral
As Cast/Scanned
Flexion
Knee Flexion Angle (degrees)
Ankle Angle
*
Neutral/Plantigrade (SVA 5deg)
As Cast/Scanned
Dorsiflexion
Plantarflexion
Calcaneal Angle
*
Neutral
As Cast/Scanned
Eversion
Inversion
Calcaneal Angle (degrees)
Toe-Out Angle
*
Neutral
As Cast/Scanned
Toe-Out
Toe-In
Toe Angle (degrees)
Toe Spring Angle
*
Standard
None
Other
Toe Spring Angle (degrees)
Shoe Pitch (mm)
Additional to other angular corrections
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)
Trimline Circ. (mm)
SupraPatellar Circ. (mm)
SupraPatellar M-L (mm)
Knee M-L (mm)
Supra Malleolar M-L (mm)
Malleolar M-L (mm)
MetHead M-L (mm)
Prox. Lat. Trim Height (mm)
Med. Lat. Trim Height (mm)
SupraPatellar Height (mm)
KJC Height (mm)
Calf Trim Height (mm)
SupraMal Height (mm)
SupraMal Height (mm)
MH Length(mm)
Trim Length (mm)
Specific Offloading and Additional Information
Contralateral 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
Contralateral 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)
Trimline Circ. (mm)
Trimline Circ. (mm)
SupraPatellar Circ. (mm)
SupraPatellar M-L (mm)
Knee M-L (mm)
Supra Malleolar M-L (mm)
Malleolar M-L (mm)
MetHead M-L (mm)
Prox. Lat. Trim Height (mm)
Med. Lat. Trim Height (mm)
SupraPatellar Height (mm)
KJC Height (mm)
Calf Trim Height (mm)
SupraMal Height (mm)
SupraMal Height (mm)
MH Length(mm)
Trim Length (mm)
2nd Specific Offloading and Additional Information
Any Additional Information
