Spine Script Pad

Spinal Bracing Script Pad
Patient Name: Date: Patient Address: Patient Phone #: UPIN #: Physician’s Name: Physician’s Signature: ™
Low Profile Brace

Small

Medium

Large

X-Large
Lumbar Orthosis
26" - 34"
32" - 40"
Waist Circumference
Measurement:
38” - 46”
_________________
44” - 51”

15º

25º

X-Small

Small

Medium

Large

X-Large

XX-Large
25” - 30”
30" - 35"
35" - 40"
40” - 45”
Waist Circumference
Measurement:
45” - 50” _________________
50” - 55”
LSO & TLSO
Spinal Orthosis
Style
Version
Lordosis

LSO

TLSO

Non-Tapered

Tapered

Low Profile

25º

15º

0º

Small

Medium

Large

X-Large
LSO

XX-Large
TLSO Options:

Dorsal Lumbar Extension 
Sternal Pad Kit
TLSO
w/ DLE
Reprint #0-2152 Rev 8/08
How to ensure a comfortable ULTRAlign®+ fit.
Sizing Guide
Refer to the unique ULTRAlign®+ orthoses measurement
system to provide a comfortable, yet efficient orthoses.
Sizing determined by three circumferential measurements:
1) 1” below tip of breast bone or xyphoid process
2) Around navel or waist
3) Around fullest area of trochanter or hips
37” - 41”
35” - 41”
38” - 42”
Xyphoid
Waist
Trochanter
38” - 45”
38” - 45”
38” - 45”
Xyphoid
Waist
Trochanter
45” - 53”
45” - 53”
45” - 53”
Low Profile
SMALL
LARGE
Xyphoid
Waist
Trochanter
MEDIUM
34” - 38”
32” - 38”
34” - 39”
25” - 31”
25” - 31”
27” - 33”
Xyphoid
Waist
Trochanter
28” - 35”
29” - 36”
32” - 38”
LARGE
MEDIUM
Xyphoid
Waist
Trochanter
Xyphoid
Waist
Trochanter
Xyphoid
Waist
Trochanter
32” - 38”
32” - 38”
35” - 41”
X-LARGE
31” - 35”
31” - 35”
31” - 35”
TAPERED LSO/TLSO
Xyphoid
Waist
Trochanter
35” - 42”
36” - 42”
38” - 46”
XX-LARGE
SMALL
Xyphoid
Waist
Trochanter
X-LARGE
TLSO
w/ SPK
XX-LARGE
NON-TAPERED LSO/TLSO
Xyphoid
Waist
Trochanter
40” - 46”
39” - 47”
43” - 49”
LSO
Backview
Ultralign® Lordosis Options:
LSO - 0º, 15º, 25º
Low Profile LSO - 15º, 25º
TLSO - 15º, 25º
TLSO
Backview