Initial Patient Evaluation for Using Posture Control Insoles™

Patient Name:

Date:

Evaluated by:

Subjective Musculoskeletal Findings

Complaints:

Neck

Other

Foot

Knee

Back

Objective Postural Findings

Red Findings

Blue Findings

Head Upright

Head Forward 

Relaxed Standing Position
Barefoot
Knees Bent 45 Degrees
Barefoot

Straight Shoulders

Rounded Shoul

Straight Back

Sway Back

Thumbs Inward

Thumbs Inward

Straight Knees

Knees Move In

Straight Ankles

Twisting Ankles

Toe-In      None

Toe-Out   None

Mild

Mild

Severe

Severe

Toe-In      None

Toe-Out   None

Mild

Mild

Severe

Severe

Left Foot

Right Foot

Walking:  Drifts to the Left

Drifts to the Right

Foot Evaluation:

Flexible Arch

Stable Arch

Flexible Cavus Arch

Rigid Foot

ILA Type:   Flat Foot

FMD:    Left Foot:

mm

Right Foot:

mm

Appraisal

Progressive Postural Arthritis

Non-Progressive Postural Arthritis

If 3 or more red objective findings are checked

If 0-2 red objective findings are checked

Plan of Action

Postural Control Insoles™ Managed Process

Recommend 3 mm Posture Control Insoles™

Progressive Postural Arthritis

Non-Progressive Postural Arthritis