UPPER EXTREMITY ORTHOTIC DOCUMENTATION WORKSHEET
Park Avenue Orthotics, Inc.
Prescribing Physician
Patient Name
Clinician Name
Date
-
Month
-
Day
Year
Date
Orthotic Dispensed
Length Humerus
Length Ulna/Radius
Circumference Forearm
Circumference Bicep
Circumference Hand
Orthotic Primary Use
Bony Prominences
Soft Tissue Conditions
Other Examination Observations
Clinician Notes
Appointment Start Time
Appointment End Time
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