Lower Extremity Orthotic Assessment Form 2026

1. Click ‘Get Form’ to open the Lower Extremity Orthotic Assessment Form in the editor.
2. Begin by entering the date, patient name, date of birth (DOB), and gender at the top of the form. This information is crucial for identifying the patient and ensuring accurate assessment.
3. In the diagnosis (DX) section, provide relevant medical diagnoses that pertain to the patient's condition. This helps in tailoring orthotic solutions.
4. Fill in height and weight fields to assess physical parameters that may influence orthotic design.
5. Indicate the GMFCS level from I-V based on the patient's mobility capabilities. Refer to the provided descriptions for accurate classification.
6. Document past treatments/interventions and outline patient/caregiver goals as well as interdisciplinary goals. This section is vital for understanding previous care and future expectations.
7. Assess muscle strength by filling out the strength grading for both left and right sides in specified muscle groups. Use grades from 5 (normal) to 0 (no activity) as per guidelines.
8. Evaluate range of motion using R1 and R2 metrics, noting any observations regarding passive range of motion.
9. Complete boney alignment assessments and observational gait analysis sections, providing detailed notes on any abnormalities observed during evaluation.

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