{literal} {/literal}
Prosthestics & Orthostics Form
Therapist
Involvement
get_involvement_left() eq 1}checked{/if}"> Left
get_involvement_right() eq 1}checked{/if}"> Right
get_involvement_bilateral() eq 1}checked{/if}"> Bilateral
Location of Evaluation
{html_options name="location" selected=$prosthesis->get_location() options=$prosthesis->location_array}
Prescription Diagnosis
Hx
get_involvement_bilateral() eq 1}checked{/if}"> Pt has worn a L.E. orthosis in the past 5 yrs.
Item to be Supplied
Model #
get_new() eq 1}checked{/if}"> New
Size
get_replacement() eq 1}checked{/if}"> Replacement
Measurements
get_foam_impressions() eq 1}checked{/if}"> Partial Weight bearing Foam Impressions
Shoe Size
Calf
Ankle
Purpose
{html_options name="purpose" selected=$prosthesis->get_purpose() options=$prosthesis->purpose_array} Other:
Notes
{$prosthesis->get_notes()|text}
get_goals_discussed() eq 1}checked{/if}"> Pathomechanics
& Orthotic goals discussed.
get_use_reviewed() eq 1}checked{/if}"> Donning, doffing, skin precautions, and orthotic use reviewed with patient
get_wear_reviewed() eq 1}checked{/if}"> Initial wear schedule reviewed with patient.
Product Longeveity And Patient Wearing Schedule
Number of years patient has worn an orthosis/prosthesis
year(s)
Age of current orthosis/prothesis
months or
year(s)
Daily wearing schedule
hours per day
Clinical Plan
get_plan_to_order() eq 1}checked{/if}"> Plan to order orthosis/prosthesis/product and fit on return date:
get_received_product() eq 1}checked{/if}"> Patient has received orthosis/prosthesis/product on this date:
get_given_instructions() eq 1}checked{/if}"> Patient been given instructions for the device/service prescribed, understands the instructions, and is able to demonstrate its appropriate use   
get_patient_understands() eq 1}checked{/if}"> Yes
{if $VIEW != true}
Add Code
{html_options options=$prosthesis->cpt_array}
[Don't Save]
{/if}