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Ultimate Podiatry Care
American Foot Clinic
Advanced Foot Care Center
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Patient Information
First Name
Last Name
Date of Birth
Gender
Male
Female
Select Shoe Size
M 1 / W 2.5 / Youth 1
M 1.5 / W 3 / Youth 1.5
M 2 / W 3.5 / Youth 2
M 2.5 / W 4 / Youth 2.5
M 3 / W 4.5 / Youth 3
M 3.5 / W 5 / Youth 3.5
M 4 / W 5.5 / Youth 4
M 4.5 / W 6 / Youth 4.5
M 5 / W 6.5 / Youth 5
M 5.5 / W 7 / Youth 5.5
M 6 / W 7.5 / Youth 6
M 6.5 / W 8 / Youth 6.5
M 7 / W 8.5 / Youth 7
M 7.5 / W 9
M 8 / W 9.5
M 8.5 / W 10
M 9 / W 10.5
M 9.5 / W 11
M 10 / W 11.5
M 10.5 / W 12
M 11 / W 12.5
M 11.5 / W 13
M 12 / W 13.5
M 12.5 / W 14
M 13 / W 14.5
M 13.5 / W 15
M 14 / W 15.5
M 14.5 / W 16
M 15 / W 16.5
M 15.5 / W 17
M 16 / W 17.5
M 16.5 / W 18
M 17 / W 18.5
M 17.5 / W 19
M 18 / W 19.5
Top Covers
Select Top Covers
Black EVA 2mm
Blue EVA 2mm
Red EVA 2mm
Mid Layer Material
Select Mid Layer Material
None
2mm P-Cell Blue
2mm P-Cell Blak
Shoe Type
Comfort
Dress
Sport
Arch Height
High
Medium
Low
Pathologies
Amputation (specify in notes)
Cavus foot
Extensor Tendinitis
Flatfoot Adult
Flatfoot Children
Hallus limitus – improve motion
Hallus rigidus – limit motion
Heel bursitis
IPK (specify in notes)
Metatarsalgia (specify in notes)
Metatarsalgia generalized – Met Bar
Neuroma
Peroneal Tendinitis
Plantar Fasciitis
Posterior Tibial Tendinitis
Prominent 5th metatarsal base
Prominent navicular
UCBL
Corrections
1st Ray Cutout
Met Bar
Metatarsal Pad
Offload metatarsal head (specify in notes)
Prominent Navicular Pad
Prominent Styloid Process Pad
Quantity
Orthotic Length
Select Orthotic Length
Full
3/4
Sulcus
Notes
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