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Universal Pedorthic Services

6037 Castor Ave.

Philadelphia, PA 19149

(215) 776-0981

Instruction Sheet for Custom Molded Orthotics

Check list

1-kitchen chair


1-foam impression kit



Step 1. Patient should sit in a chair

Step 2. Helper should open foam impression kit

Step 3. For heel spurs or pain under ball of feet, use index finger to locate area of
pain and mark the bottom of foot where pain is located with lipstick

Step 4. Helper should press left foot in box then right foot

Step 5. Helper should apply all pressure with no help from patient

Step 6. Both heel and forefoot should be pressed all the way to bottom of box


  • For flat feet, apply pressure to heel and forefoot down without placing pressure on arch area
  • For high and medium arch, apply pressure to heel and forefoot in addition to arch area
  • Be sure that all toes are pressed to bottom of foam impression kit, unless the kit is to short
  • Please ship your foam box within a shipping box.

Please enter your information and return this sheet with your mold.



Phone number__________________________________________________________

Weight and your size shoe_______________________________________________________

Is your arch high, medium, or low_________________________________________

Are you diabetic______________________________________________________

Universal Pedorthic Services

Custom Molded Orthotics * Shoe Modifications * Orthopedic Shoes & Sneakers

6037 Castor Ave. Philadelphia, Pa. 19149 215-776-0981 [email protected]

Custom Molded Orthotic Questionnaire

Please Circle If You Have The Following Conditions:

1) Flat Feet

2) Heel Spurs—Circle Left , Right or both

3) Ankle Fusion-Left Or Right

4) Screws In Your Foot

5) Plantar Fasciitis

6) Bunions

7) A High Arch

8) A Low Arch

9) Metatarsalgia Or Ball Of The Foot Pain

10) Pronation

11) Supination

12) Diabetes

13) Arthritis In Your Feet

14) Weak Ankles

15) Knee Pain

16) Back Pain

17) Leg Length Discrepancy- If Yes Please Specify

Special Instructions: ______________________________________________________________

Please Return This Form With Your Mold