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Please PRINT clearly. 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Yes / No) /Pg 7 0 R >> endobj 37 0 obj << /Type /StructElem /S /P /ActualText /Pg 7 0 R >> endobj 38 0 obj << /Type /StructElem /S /P /ActualText (Is an orthosis required prior to discharge? Yes / No / Uknown) /Pg 7 0 R >> endobj 39 0 obj << /Type /StructElem /S /P /ActualText /Pg 7 0 R >> endobj 40 0 obj << /Type /StructElem /S /P /ActualText /Pg 7 0 R /K [3] >> endobj 41 0 obj << /Type /StructElem /S /P /ActualText (Objectives of Orthotic Treatment: \(Tick all that apply\)) /Pg 7 0 R /K [4] >> endobj 42 0 obj << /Type /StructElem /S /P /ActualText /Pg 7 0 R /K [5] >> endobj 43 0 obj << /Type /StructElem /S /P /ActualText /Pg 7 0 R /K [6] >> endobj 44 0 obj << /Type /StructElem /S /P /ActualText (Offload ulcer Reduce the risk of contractures Reduce the risk of falls ) /Pg 7 0 R /K [7] >> endobj 45 0 obj << /Type /StructElem /S /Figure /P 14 0 R /Pg 7 0 R >> endobj 46 0 obj << /Type /StructElem /S /Figure /P 14 0 R /Pg 7 0 R >> endobj 47 0 obj << /Type /StructElem /S /Figure /P 14 0 R /Pg 7 0 R >> endobj 48 0 obj << /Type /StructElem /S /Figure /P 14 0 R /Pg 7 0 R >> endobj 49 0 obj << /Type /StructElem /S /Figure /P 14 0 R /Pg 7 0 R >> endobj 50 0 obj << /Type /StructElem /S /Figure /P 14 0 R /Pg 7 0 R >> endobj 51 0 obj << /Type /StructElem /S /Figure /P 14 0 R /Pg 7 0 R >> endobj 52 0 obj << /Type /StructElem /S /Figure /P 14 0 R /Pg 7 0 R >> endobj 53 0 obj << /Type /StructElem /S /Figure /P 14 0 R /Pg 7 0 R >> endobj 54 0 obj << /Type /StructElem /S /Figure /P 14 0 R /Pg 7 0 R >> endobj 55 0 obj << /Type /StructElem /S /Figure /P 14 0 R /Pg 7 0 R >> endobj 56 0 obj << /Type /StructElem /S /H3 /T ( Relevant History: Please include pathology, presentation, and prognosis) /E ( Relevant History: Please include pathology, presentation, and prognosis) /Pg 7 0 R /K [33] >> endobj 57 0 obj << /Type /StructElem /S /H2 /T (To be completed by the Orthotics Department only) /E (To be completed by the Orthotics Department only) /Pg 7 0 R /K [31] >> endobj 58 0 obj << /Type /StructElem /S /P /ActualText (Triaging Orthotist \(Print Name\): ............................................................................................................................. ) /Pg 7 0 R /K [21] >> endobj 59 0 obj << /Type /StructElem /S /P /ActualText (Date referral received: ................................... 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