Custom Scoliosis / Kyphosis Orthometry Form Order

Custom Scoliosis / Kyphosis Orthometry Form
PATIENT INFORMATION
ID / Name___________________________
M F Height________Weight________
Age________Diagnosis_______________
__________________________________
__________________________________
MATERIALS
Co-Poly
Finished Thickness
MPE
1/8" 5/32" 3/16"
LDPE
Aliplast Liner
1/8" 3/16" 1/4"
No Liner
Scoliosis Design
Low Profile TLSO
Anterior Open
Posterior Open
Milwaukee
Wilmington
Dynamic
Other_______________
Kyphosis Design
Low Profile TLSO
T-bar / Sternal
High Profile
Aluminum Para-Spinal
Bars
Milwaukee
Note: X-Rays must be
supplied for all
scoliosis requiring
correction
Lordosis __________
Circ Width
CUSTOMER INFORMATION
Date________Date Req'd________PO#___________
Company____________________________________
Ship To______________________________________
Contact ________________Phone_______________
Ship Via________On________Fax_______________
Order #
Please Indicate
Special Trimlines
Pad Placement
Window Cut-Out
CORRECTIVE PADS
Lumbar L
R
Dynamic
Thoracic L
R
Dynamic
Axilla Axillary Sling
Trochanter
Apply per X-Rays
Send Pads
Waist Pads
MILWAUKEE SUPER STRUCTURE
Neck Ring
High Profile
Low Profile
Kyphosis Pads
Attached to Posterior
Uprights
Floating w/ Outrigger
Finished
Thoracic Window
Unfinished
Yes
No
Transfer Pattern_____________
Notes_____________________
__________________________
__________________________
______________________
A-P
IMPORTANT: If finished measurements are not supplied
your orthosis will be trimmed to the anatomical measurements
Measurements below are:
Anatomical
Finished Trim
Milwaukee only
Chin (Milwaukee only)
Neck
Top of
Shoulder
Superior
Scapula
Sternal Notch
Axilla
Nipple Line
Xyphoid
Nipple Line
Xyphoid
Lower Rib
6333 N Orange Blossom Trail Orlando, FL 32810
Voice 877-737-8444 Fax 877-737-8445 e-mail [email protected]
Inferior
Scapula
ASIS
Sym Pubis
Trochanter
Axilla
Waist
Waist
ASIS
Occiput
Coccyx
Troch
SL 00070 Rev. A
G-Fold