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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-helper
1-foam
impression kit
1-lipstick
Procedures
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
Note:
- 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.
Name__________________________________________________________________
Address________________________________________________________________
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
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