E-mail Address: *
Date * Select Date
First Name *
M.I.
Last Name *
Foot that is injured *Right
Left
Nature of injury *Ankle
Foot
Achilles tendon
Other
Foot immobilized by *Hard cast
Soft cast
Brace
Other
Patient Height Inches *
Patient Weight Lbs *
Patient Age *
Patient Sex *
Male
Female
Level of coordination *
Taking medications that make patient dizzy or light-headed? *
Yes
No
Intended use of RollerFoot? *At Home
At Work
Outside
Other
Predominant surface to be used on? *
Hard smooth floors
Carpeted floors
Sidewalks
Number of weeks to be used? *
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