Scoliosis Questionnaire

Scoliosis Questionnaire

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

First NameLast Name
Date of Birth*

MonthDayYear
Birth History
Please describe any pertinent information regard the birth of the child (ie: premature, NICU stay, birth trauma). *
Please check the mobility description(s) that best describe the child*

Fully IndependentSits IndependentlyStands IndependentlyWalks IndependentlyWalks with AssistanceWheelchair use for Mobility
Medical History
Which physician is currently managing the child’s scoliosis?*
Does child have a history of the following concerns:*

TorticollisHip displasiaKyphosisLeg Length DiscrepancyBack PainVertebral AnomaliesSkin sensitivitiesSensory ConcernsAutismSpina BifidaCerebral PalsyMedically ComplexNoneOther
Are there any other medical considerations that should be noted?
When was the scoliosis first noted/diagnosed?*
What type of scoliosis was diagnosed (if known)?*

IdiopathicNeuromuscularCongenitalUnknownOther
If female, has menarche occurred? If yes, when was the date of first menstruation?*
Brace History
Has the child used a scoliosis brace before?*

YesNoUnknown
If yes, please describe the child’s history with bracing. What styles have has worked well in the past, and what challenges have you experienced?*
Is the child participating in a physical or occupation therapy program? If so, where and with whom?*
Has any imaging been done?*

NoYes, X-rayYes, CTYes, MRI
Date of most recent X-Ray?
Has any surgical intervention been performed?*

YesNo
What are your main goals for treatment? *
What sports or activities your child participates in that could be affected by brace wear?*
Are there any specific concerns or questions you want addressed at the appointment?*
I certify that the above information is correct to the best of my knowledge:*

Agree
Thank you for filling out this questionnaire — it really helps us prepare for your visit.

At the appointment, we’ll take measurements, photos, and, if needed, a 3D scan so we can get a clear picture of your child’s spine. We’ll talk about how bracing will help, answer your questions, and walk you through what treatment could look like.

We’re here to support your family through every step of this journey.

See you soon!
Should be Empty:

Scoliosis Questionnaire

Birth History

Medical History

Brace History