Custom Foot Orthoses Evaluation & Casting Note

Date/Time: [Date and time of encounter]

Location: [Clinic/site]

Encounter Type: [initial evaluation / re-evaluation / casting-only / scan-only]

Clinician: [Name, credentials]

Referring Provider: [Name, credentials] (Include only if applicable.)

Prescription Status: [received / pending / generated today]

Attachments: [Photos, gait video, pressure mapping, scan files captured today] (List items captured or state none.)

Chief Concern and Indications

[Chief concern with brief patient quote if available; working indication for orthoses (pain, instability, deformity accommodation, pressure redistribution, gait efficiency); primary functional limitation with measurable context such as walking tolerance or pain level with specific activity; laterality] (Keep to 2–4 lines total.)

Subjective

History of Present Condition

[Narrative summary: onset and duration; location and laterality; severity using pain scale; temporal pattern (morning vs activity-related, improving/worsening/fluctuating); aggravating factors (footwear types, surfaces, activities); alleviating factors (rest, shoe changes, taping, stretching, prior orthoses); red flags if present]

Prior Treatments and Response

• [Footwear and OTC inserts tried with outcomes and reasons for success/failure]
• [Prior custom orthoses: specifications if known, outcomes, and failure modes]
• [Physical therapy or exercises and response]
• [Taping, immobilization, injections, or medications and response]
• [Relevant imaging already performed and key findings]

Functional Status and Goals

• [Baseline functional limitations affecting ADLs, work duties, sport/training, standing/walking requirements]
• [Gait aid use and fall history if instability is an indication]
• [Patient-stated goals in their terms]

Relevant Medical History

• [Diabetes status and control; peripheral neuropathy; peripheral vascular disease]
• [History of ulceration or amputation]
• [Rheumatologic conditions; edema/CHF; neurologic conditions]
• [Material allergies or sensitivities]

Footwear

[Typical shoes by category (work, athletic, dress) with size/width, removable insole presence, heel height, wear patterns; required footwear constraints (uniforms, PPE, cleats, safety toe)]

Objective

(Document clinician-observed findings only. Include laterality throughout. Provide side-to-side comparisons when meaningful. Omit domains not assessed; for core safety domains, state "Not assessed: [reason]" if not performed.)

Inspection and Integument

• [Skin integrity: callus pattern and location, fissures, maceration, blistering, erythema, wounds with size/location if present]
• [Edema with grade if present]
• [Visible deformities: hallux valgus, hammer toes, prominent metatarsal heads, arch height, heel alignment]

Neurovascular Status

• [Pulses, capillary refill, temperature symmetry]
• [Protective sensation screen if indicated and within scope]
• [Neurogenic pain patterns if relevant]

Range of Motion and Strength

• [Ankle dorsiflexion (specify knee position if both tested)]
• [Subtalar and midtarsal mobility; first MTP dorsiflexion]
• [Muscle testing: posterior tibialis, peroneals, gastrocnemius/soleus; calf flexibility]
• [Single-leg heel raise performance if tested]

Palpation

• [Point tenderness locations (plantar medial calcaneal tubercle, posterior tibial tendon, metatarsal heads, peroneals, etc.)]
• [Symptom reproduction with specific maneuvers]

Foot Posture and Biomechanics

• [Weight-bearing alignment: calcaneal position, arch behavior under load, knee valgus/varus tendency, limb rotation]
• [Leg length discrepancy if assessed with method noted]
• [Existing orthoses if present: fit, wear pattern, posted features, failure modes]

Gait Assessment

• [Observation conditions: barefoot vs shod, with/without orthoses, surface, speed, assistive device]
• [Key observations: initial contact pattern, tibial progression, heel rise timing, pronation/supination, medial arch collapse, toe-off mechanics, step width, cadence, symmetry, antalgic patterns, trunk lean]
• [Objective tools used: timed walk test, video capture, plantar pressure mapping]

(If gait not assessed, state reason and proxy information used. This is a core section for this template type.)

Baseline Outcome Measures

• [Pain scale at rest and with typical aggravating activity]
• [Walking and/or standing tolerance (time/distance)]
• [Standardized functional measure if used with tool name and score]

Assessment

Diagnoses and Clinical Impressions

• [Working diagnosis/clinical impression] [ICD code if required]
• [Additional diagnoses as needed]

Biomechanical Analysis

[Hypothesized mechanical contributors supported by exam findings; link observed impairments to loading patterns and symptoms (e.g., limited ankle dorsiflexion contributing to early heel rise and increased forefoot pressure)]

Risk Factors

[Specific risk factors present, ulcer risk level, whether accommodative/offloading features are required for safety] (Include for patients with diabetes, neuropathy, vascular disease, or history of ulceration; omit if not applicable.)

Rationale for Custom Orthoses

[Explicit justification for custom devices over prefabricated: significant deformity requiring accommodation; need for multi-parameter control; documented failure of appropriate prefabricated trial; high-risk pressure redistribution needs; tie to specific measurable impairments and functional limitations] (This section is required.)

Orthoses Prescription

Device Specifications

Type: [functional / accommodative / sport-specific / diabetic-offloading]

Laterality: [left / right / bilateral]

Length: [full-length / 3/4]

Target Shoe Category: [Shoe category]

Shell: [Material and rigidity with rationale]

Top Cover: [Material and thickness with rationale]

Corrective/Accommodative Features: [Rearfoot posting, forefoot posting, heel skive, heel cup depth, arch contour, metatarsal pad, heel pad, cut-outs/apertures, offloading channels, first ray accommodation, lateral/medial flange] (List only features ordered with specifications.)

Functional Goals

1. [Pain goal: target intensity with activity context; timeframe]
2. [Function goal: walking/standing tolerance targets or return-to-activity goals; timeframe]
3. [Skin integrity goal with monitoring plan; timeframe] (Include for high-risk patients.)

Wear Schedule

[Break-in progression (hours per day over days/weeks); shoe compatibility requirements (depth, width, removable insole); warning signs requiring discontinuation and clinic contact (blistering, persistent redness, new numbness, wounds)]

Casting/Scanning Procedure

Consent: [Informed consent obtained; risks discussed]

Pre-Procedure Check: [Skin status before capture]

Method: [plaster cast / foam box impression / 3D scan] [weightbearing / partial weightbearing / non-weightbearing]

Positioning: [Foot positioning technique, knee position, forefoot manipulation if performed]

Quality: [Completeness of capture; artifacts and mitigation]

Identifiers: [Scan file name/ID, lab order number, cast labeling with patient ID, side, date]

Tolerance: [Patient tolerance; adverse events or aftercare if applicable]

Plan

1. [Orthoses fabrication order status, lab/vendor, expected timeline]
2. [Delivery/fitting appointment]
3. [Follow-up reassessment plan: outcomes to remeasure and timeframe]
4. [Co-interventions: footwear recommendations, exercises, PT referral, offloading precautions]
5. [Communication with referring provider]

Patient Education Provided: [Break-in schedule reviewed and provided in writing; skin self-inspection instructions; cleaning and maintenance; expected adaptation period; patient understanding confirmed or barriers identified]