Cranial Questionnaire

Cranial Questionnaire

Please complete the following questionnaire below at least 24 hours before your appointment.
Patient Name*

First NameLast Name
Date of Birth*

DayMonthYear
Birth History
Please provide any relevant details about your baby’s birth (e.g., vaginal or C-section delivery, use of forceps or suction, breech or unusual positioning, premature birth, NICU stay, or birth-related trauma).*
Is baby a twin or multiple*

YESNO
Please check all milestones that have been met?*

Rolling back to bellyRolling belly to backSitting with assistanceSitting independentlyGetting onto hands and kneesCrawlingPulling to standWalkingNo milestones achieved yet
What position does baby sleep in*

on backon tummyon side
Do you have any concerns about milestone achievements or developmental delays?
Medical Concerns
Does baby have any history of the following concerns:*

Tongue-tieTorticollisSkin sensitivitiesTroubles with feedingHip displasiaAcid refluxChronic ear infectionsNo medical concerns
Are there any other medical considerations that should be noted?
Head Shape Concerns
When did you first notice the head flatness?*
What are your primary concerns with head shape?*
Describe how you have been working to prevent baby's head shape from getting worse?*
Has any imaging been done on baby's head?*

NoYes, X-rayYes, CTYes, MRI
On a scale of 1-5, how would you rate the severity of your baby's head shape?*

1

2

3

4

5

1 is Mild, 5 is Very Severe
On a scale of 1-5 how concerned are you with baby's head shape?*

1

2

3

4

5

1 is Not Concerned, 5 is Very Concerned
Thank you so much for taking the time to fill out this questionnaire, it is extremely helpful to have this information ahead of time. If you are wondering what to expect at your upcoming appointment, we will collect objective data through measurements, pictures, and a 3D surface scan. With this information, we will categorize your baby's head shape and make a recommendation as to whether or not a helmet would be an appropriate intervention. We will go over FAQ's regarding head shapes and helmet treatment and will discuss what that journey looks like if we determine a cranial remolding helmet is the best option.

See you soon!
Should be Empty:

Cranial Questionnaire

Birth History

Medical Concerns

Head Shape Concerns