Custom Scoliosis / Kyphosis Orthometry Form

PATIENT INFORMATION CUSTOMER INFORMATION

ID / Name___________________________
M F Height________Weight________
Age________Diagnosis_______________
__________________________________
__________________________________
Date________Date Req'd________PO#___________
Company____________________________________
Ship To______________________________________
Contact ________________Phone_______________
Ship Via________On________Fax_______________

MATERIALS
Order #
Scoliosis Design
Low Profile TLSO Co-Poly Finished Thickness Please Indicate
Anterior Open Posterior Open MPE 1/8" 5/32" 3/16" Special Trimlines
Milwaukee Pad Placement
LDPE Aliplast Liner Window Cut-Out
Wilmington 1/8" 3/16" 1/4"
Dynamic No Liner CORRECTIVE PADS
Other_______________ Lumbar L R
MILWAUKEE SUPER STRUCTURE Dynamic
Neck Ring Thoracic L R
Kyphosis Design
High Profile Dynamic
Low Profile TLSO
Low Profile Axilla Axillary Sling
T-bar / Sternal
Kyphosis Pads Trochanter
High Profile
Attached to Posterior Apply per X-Rays
Aluminum Para-Spinal
Uprights Send Pads
Bars
Floating w/ Outrigger Waist Pads
Milwaukee
Finished Unfinished
Note: X-Rays must be
Thoracic Window Yes No
supplied for all
scoliosis requiring Transfer Pattern_____________ IMPORTANT: If finished measurements are not supplied
correction Notes_____________________ your orthosis will be trimmed to the anatomical measurements

__________________________
Lordosis __________
__________________________ Measurements below are:

Circ Width A-P ______________________ Anatomical

Finished Trim
Occiput
Chin (Milwaukee only) Milwaukee only
Neck
Top of
Sternal Notch Shoulder
Superior
Axilla
Scapula

Nipple Line Nipple Line

Axilla Inferior
Xyphoid
Scapula
Xyphoid
Lower Rib
Waist
Waist

ASIS
ASIS
Sym Pubis Coccyx
Troch G-Fold
Trochanter
6333 N Orange Blossom Trail Orlando, FL 32810
Voice 877-737-8444 Fax 877-737-8445 e-mail custserv@orthomerica.com SL 00070 Rev. A