Thermoplastic AFOs Compliance Documentation Packet | Page 2

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DCNPAFO170913
Biomechanical Evaluation Form
Patient Name : Chief Complaint : History of problem : Nature of discomfort / pain Location ( anatomic ) Duration Onset Course Aggravating and / or alleviating factors
Left
Stance Evaluation :
Right
Normative values :
Treatments and response
Angle of gait : → Base of gait : → Foot appearance Tibial infl uence
0˚-2˚ varus or valgus
Relaxed calcaneal stance position ( RCSP )
0˚
Neutral calcaneal stance position ( NCSP )
0˚
Non-Weight Bearing Evaluation : Limb length : →
Equal
Hip sagittal plane- Knee extended
Flexion 120˚ / extension 20-30˚
Knee fl exed
Flexion 45-60˚ / extension 20-30˚
Hip transverse plane- Knee extended
45˚ each direction
Knee fl exed
45˚ each direction
Hip frontal plane
45˚ each direction
Knee sagittal plane
Flexion 120˚ / extension 0-10˚
Knee recurvatum
Absent
Ankle sagittal plane- Knee extended
Dorsifl exion 10˚ / plantarfl exion 40-70˚
Knee fl exed
Dorsifl exion 10˚ / plantarfl exion 40-70˚
Subtalar joint- Inversion
20˚
Eversion
10˚
Subtalar joint axis location Midtarsal joint
0˚
1 st ray range of motion
Dorsal & plantar excursion 5mm
1 st MTPJ range of motion
Dorsal 65˚ or > unloaded / 20-40˚ loaded
Lesser MTPJ ’ s Other comments :
Muscle testing ( extrinsics ): Invertors Evertors Dorsiflexors Plantarflexors Neurological testing : Romberg→ Patellar reflex Achilles reflex Babinski Clonus Protective sensation Gait Evaluation - Gait pattern
Comment on head / shoulders , spine , pelvis , sagittal / transverse / frontal plane , postural , etc .
Footgear ( size / width , wear pattern ( s )) → Existing orthoses / type→ Weight→ Height→ Biomechanical assessment : Treatment plan : Enter assistant name Signature of assistant
5 / 5 : normal strength 5 / 5 : normal strength 5 / 5 : normal strength 5 / 5 : normal strength
Balance intact 2 + normal 2 + normal No hallux extension Absent Present
Enter date of exam Signature of physician
Save in patient ’ s chart
The Medicare Program Integrity Manual , states that “ For any DMEPOS item to be covered by Medicare , the patients medical record contains suffi cient documentation of the patients medical condition to substantiate the necessity for the type and quantity of the items ordered .