Orthotic Questionnaire

Orthotic Questionnaire

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

First NameLast Name
Date of Birth*

MonthDayYear
Developmental History
Please provide any important information regarding growth and development up until this time*
Please check all milestones that have been met?

Sitting independentlyGetting onto hands and kneesCrawlingPulling to standCruisingWalkingRunningJumping
Do you have any concerns about milestone achievement or developmental delays?
Has the child has any orthotic braces or interventions previously?*

YesNo
If YES, please describe:
If YES, what worked well, and what did you have challenges with?
Medical Concerns
Does baby have any history of the following health concerns:*

TorticollisSkin sensitivitiesSpacticityFeeding difficultiesHip displasiaSeizuresDevelopmental delaysScoliosisVisual impairmentsHearing impairmentsRespiratory issuesNoneOther
Are there any other medical considerations that should be noted?
Treatment Goals
What do you understand the goals of the device to be (check all that apply)*

Improved stability for standingImproved walking and balancePrevent deformityIncreased mobility for play and social activitiesPain relief
What activities or task are most challenging for your child?
Does the child use any assistive devices for mobility:*

NoYes, WalkerYes, WheelchairYes, Crutches
Does the child participate in Physical Therapy? If yes, for how long, with whom, at what clinic?*
Is there anything else you would like us to know about the child's needs, challenges, or goals?
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 videos. With this information, we will perform a gait analysis and determine the best treatment option(s) for the child. If there are multiple appropriate treatment options we will review with your family and caregivers to determine which is best for the overall quality of life.

See you soon!
Should be Empty:

Orthotic Questionnaire

Developmental History

Medical Concerns

Treatment Goals