DAFO Brace Planning · Strong Planned Brace Style: Planned Position for Brace: (Patient must be...
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1 2 8 9 3 4 5 6 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 Planning S O A P Transcribed By: Coordinating Therapist: Clinical Location: Cascade Dafo, Inc. 1360 Sunset Avenue Ferndale, WA 98248 ph: 800.848.7332 fax: 877.856.2160 intl: + 00 1 360 543 9306 www.cascadedafo.com
Transcript of DAFO Brace Planning · Strong Planned Brace Style: Planned Position for Brace: (Patient must be...
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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
