Header image
Marmaduke Loke

Phone: Office: 760-814-8475
Email: info@DynamicBracingSolutions.net

  
 

 

 
 
Video Filming Instructions:
O&P Pro® is a registered trademark of the DynamicBracingSolutions™ network.    

O&P Pro4®  

Questionnaire Form

For: ________________ ________________

Date: ________________

1. What is the name of your disease or problem? __________________________________________

2. What was the year of onset? ___________ Diagnosis? ___________ Years since onset? ________

3. What assistive devices do you presently use? ___________________________________________

4. What kind of braces do you presently use? ____________________________________________

5. How far can you presently walk barefoot? _____________________________________________

6. How far can you presently walk with your current braces? ________________________________

7. What prevents you from walking further? _____________________________________________

8. How many falls do you have per day? ________ Week? _______ Month? _______ Year? _______

9. Do you have difficulty standing still barefoot? __________________________________________

10. How would you rank your security barefoot? (1-10) 1= poor _____________________________

11. How would you rank your security with current braces? (1-10) ___________________________

12. How would you rank your balance barefoot? (1-10) ____________________________________

13. How would you rank your balance with current braces? (1-10) ___________________________

14. Do you feel your feet? _________ Ankles? _________ Legs? _________ Knees? ____________

15. Do you have vestibular problems (inner ear balance problems)? ___________________________

16. Do you have visual (eyesight) problems? _____________________________________________

17. Do you have circulation problems? _________________________________________________

18. Do you have edema or swelling in the foot? __________ Ankles? _________ Legs? __________

19. Do you have pain? ________ Location? _______________________ Rank Pain (1-10): _______

20. Are you independent at home? __________________ In the community? __________________

21. Do you currently work? __________________________________________________________

22. List other factors that may impede or limit your function:
_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________
 

O&P Pro® is a registered trademark of the DynamicBracingSolutions™ network.
 

 O&P Pro4®
 
Photographic & Video Consent Form

Procedure:

A representative of DynamicBracingSolutions™ (or someone assisting you) will take video films and photographs of you standing and walking with and without assistive devices. Such devices may include canes, crutches, orthoses, or prostheses. You will be requested to wear either shorts or bathing suit during the filming process.

Purpose:

This photographic and video graphic evaluation procedure is an integral aspect of DynamicBracingSolutions'™ process of gait shaping. Consent is required for the process to begin. A DBS licensed clinician will analyze this information with the aid of computer programs. This information will help to determine the degree of the structural correction possible. It also becomes the baseline for all future comparisons.

Consent:

I consent to the taking of pictures (video graphic or photographic of all formats) of my injury, physical condition, orthosis, or prosthesis by a DynamicBracingSolutions™ trained staff member or myself, to help determine the degree of the structural correction possible. The video may be used to educate other DynamicBracingSolutions™ members and to demonstrate outcomes to other healthcare professionals.
The data is also utilized for research purposes. This material is to remain confidential and cannot be used for any other purpose without my approval.
 
Name: ________________________________________________ Date: ________________
 

Media Consent:

I consent to the taking of pictures (video graphic or photographic of any format) of my injury, physical condition, orthosis, or prosthesis by a DynamicBracingSolutions™ trained staff member or myself to show other potential patients/clients, for education purposes or media purposes.

Name: ________________________________________________ Date: ________________
 

O&P Pro® is a registered trademark of the DynamicBracingSolutions™ network.
18. L
Midswing
(1.5" X 3")
19. R
Midswing
(1.5" X 3")

20. post
body Rt.
stance
(2"" X 4")

21. post.
body Lt.
stance
(2" X 4")

22 Right
step
(2" X 3")

23. Left
Step
(2" X 3")

18.1
19.1
20.1
21.1
22.1
23.1
11. Ant.
limbs, pelvis
(2" X 3")
12. Ant.
L limb
(1.5" X 3")

13. Ant.
R limb
(1.5" X 3")

14. Left Lat.
Limb
(1.5" X 3")

15. Rt. Lat.
Limb
(1.5" X 3")

16. Body L.
Midstance
(1.5" X 3")

17. Body R.
Midstance
(1.5" X 3")

11.1
12.1
13.1
14.1
15.1
16.1
17.1
08. Left
medial foot
(2" X 2")
09. Right
medial foot
(2" X 2")

10. Static
Post Feet
(2" X 2")

08.1
09.1
10.1
02. Left
anterior foot
(2" X 2")
03. Right
anterior foot
(2" X 2")

04. Left
post. foot
(2" X 2")

05. Right
post. foot
(2" X 2")

06. Left
lateral foot
(2" X 2")

07. Right
lateral foot
(2" X 2")

02.1
03.1
04.1
05.1
06.1
07.1
01.
Patient face
(2" X 2")
01.1
  1. Create a folder in the 'Client Eval Graphics' folder located within the O&P Pro Folder
  2. Name the folder: Client's Last Name, Client's First Name. Example: Doe, Jane
  3. Grab the required video frames listed below.
  4. Name each frame by their corresponding number, i.e. 01, 02, etc..
  5. Enter the captured frames in the client's folder described above.
Recommendations:
  1. Request that the client bring and wear shorts or a bathing suit that is at least 3" above the knee.
  2. Keep video camera as level and still as possible. Use a tripod if necessary.
  3. Have adequate lighting. Outside filming presents contrast problems if there is bright sunlight.
  4. Find a safe environment; attempt the following filming procedure if the client can walk safely. Parallel bars for security may sometimes be necessary.
  5. Use any NTSC or digital video format.


Filming: (If you film as indicated, the required frames indicated below will be captured.)
  1. Film a close up of smiling face; elicit the following from the client:
    1. name, age, weight, height,
    2. brief medical history,
    3. goals, concerns, wishes.
  2. Film the anterior patient standing STATICALLY fully including waist to feet (5 seconds).
  3. Film the posterior patient standing STATICALLY fully including knees to feet (5 seconds).
  4. Film 1-2 minutes antero-posteriorly walking down and back twice.
  5. Film 1-2 minutes medio-laterally walking down and back twice.
  6. Repeat steps 2-5 if the client is currently using an external mechanical device such as an orthosis or prosthesis.

 
O&P Pro® is a registered trademark of the DynamicBracingSolutions™ network.•Video

   O&P Pro4®
Frames for Mechanical Evaluations

Instructions
:
Personal Information:
 
Name: _____________________________

Age: __________ Date: _______________

Weight: ____________ Height: _________

Phone: ____________________________
Measurements:
  1. Measure the length of both feet:
    1. Left Foot Length: _________
    2. Right Foot Length ________
  2. Measure the length of both shoes (not size):
    1. Left Shoe Length: ________
    2. Right Shoe Length: _______
  3. Measure the posterior standing base (mid-calcaneus to mid-calcaneus):
    1. Standing Base: ___________
  4. Measure the pelvis width (trochanteric level): ____________
O&P Pro4®  
1camera.1

Video Filming Instructions:
© 2000-2010 Marmaduke Loke
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