Please complete the information requested below



Ankle Foot Orthosis Patient History

Please fill out this form. The information will be used to determine whether your insurance will pay for the device your physician has prescribed.

Activities or Hobbies: Check all that apply:

○ Swimming ○ Hiking ○ Biking ○ Boating ○ Fishing ○ Baseball ○ Golf ○ Running ○ Skiing ○ Sewing ○ Volleyball ○ Watching Television ○ Reading ○ Crafting ○ Travel ○ Other______________________

Where is most of your walking done?

○ Within the Home Only ○ Outside the Home ○ For Recreation and/or Exercise

On an average day, how do you spend most of your time? ○ Standing ○ Sitting ○ Walking

Do you drive? ○Yes ○No The device is for the: ○ Right Side ○ Left Side ○ Both (Bilateral)

Please check any of the following which you use to perform daily activities:

○ Walker ○ Cane ○ Quad Cane ○Wheelchair ○ Chore Service ○ Visiting Nurse ○Attendant

Medical History:

Have you been treated for, or do you now have any of the following:

○Vascular Disease (Poor Circulation) ○ Diminished Hand/Finger Coordination ○ Shingles ○ Polio

○ Paralysis ○ Foot Injury/Trauma ○ Knee Instability ○ Guillain Barre Syndrome ○ Drop Foot

○ Foot Pain ○ Weakness in legs ○ Nerve Injury ○ Neurological Disease ○ Stroke/CVA

○ Back Pain ○ Loss of Sensation in legs ○ Weakness in hands ○ High blood pressure ○ Hip Pain

○ Back Injury ○ Compression stockings ○ Loss of Sensation in hands ○ Diabetes ○ Arthritis

Do you have diabetes? ○Yes ○No If yes, please complete the following section:

Name of Physician who treats your Diabetes: _______________________________________

How long have you been Diabetic? _______________________________________________

Please indicate which best describes your present diabetic treatment:

○ Diet only ○ Oral Insulin ○ Insulin injection ○ Dialysis ○Untreated

Please indicate which of the following conditions you have been treated for:

○ Calluses of the feet ○ Neuropathy ○ Amputation of toe(s) ○ Loss of sensation

○ Ulcers of the feet ○ Orthopedic footwear (shoes or inserts) ○ Poor circulation

Please explain why your doctor has prescribed this brace for you: _____________________________

____________________________________________________________________________________

Have you ever worn any type of leg or foot brace in the past? ○Yes ○No If yes, complete the following:

Type of Brace: ________________________Prescribing Doctor: _______________________________

Reason for wearing brace: _____________________________Began using: ______________________

Are you presently using this brace? ○Yes ○No If no, explain _________________________________

If you are covered by Medicare or a Medicare Supplement, please read the following:

Medicare has informed us that the useful lifetime of any prosthesis or orthosis is five years. Payment for replacement devices will be considered only under the following circumstances:

□ The item has been lost or stolen.

□ The item is irreparably damaged or worn.

□ The patient’s medical condition has changed.

Medicare will require proof of loss or damage through documentation such as a police report, picture or corroborating statement.

I hereby certify that I have answered the above questions to the best of my knowledge and that the answers are complete and true. I understand that if my insurance should deny payment, I will be held financially responsible for the bill. Douglass Certified Prosthetics and Orthotics, Inc. will make every effort to ensure payment of the claim on my behalf.

Patient Signature______________________________________________Date_____________

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