1

2

8

9

3456

7

Patient Name: DOB:

Today’s Date: Current Brace Style / History:

Diagnosis:

Patient Information: (History, subjective and objective reports)

Suggested considerations:

y Foot

y Ankle

y Knee

y Gait Without Bracing

y Gait With Bracing

y Position of Function/Resistance to

y Functional Goals

Patient Presentation: Primary: Other:

Level of Involvement: Choose one: Mild Moderate Strong

Planned Brace Style:

Planned Position for Brace:(Patient must be correctable to this position)

Hindfoot: Forefoot: Ankle:

Optimizations?

Additional Notes:Plan (expected outcome, follow-up)

Signature: Date:

Brace Planning Worksheet (Rev: 04 June 2012)

DAFO Brace PlanningS

OA

P

Transcribed By:

Coordinating Therapist: Clinical Location:

Cascade Dafo, Inc. 1360 Sunset AvenueFerndale, WA 98248

ph: 800.848.7332fax: 877.856.2160

intl: + 00 1 360 543 9306www.cascadedafo.com