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Scoliosis Eval
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Scoliosis Eval
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Pt Name
*
DOB
Age
Sex
M
F
Date
Insurer
Physician
Service
Practitioner
HT
WT
Diagnosis
Primary problem
Areas of pain
Current PE/sports activities
Age first diagnosed
Have X-rays been taken
Yes
No
Number of X-rays taken
Previous surgeries and dates
Physical therapy
None
Ongoing
Forthcoming
Frequency
Therapist
Other treatments
Have you worn an orthosis (brace) before
Yes
No
Last orthosis type
Made by
How old?
Still being used
Yes
No
Problems with previous orthosis
Specific requests of this new orthosis (brace)
Comments
X-rays presented for review
Yes
No
King/Brace Class
L(A)
1(B)
2(C)
3A(D
3B(E)
4(F)
5
SRS Class
Lumb
T-L
Thoracic
Double
Physical Exam:
Est. Brace Class
L(A)
1(B)
2(C)
3A(D
3B(E)
4(F)
5
Flexibility
High
Mod
Low
Primary: Type
L/R
Left
Right
deg
apex
Secondary: Type
L/R
Left
Right
deg
apex
Tertiary: Type
L/R
Left
Right
deg
apex
Decompensation:
To L/R
Left
Right
Hypokyphosis
None
Mild
Mod
Severe
L4 tilted to
Left
Right
Leg length discrepancy (which lower)
Left
Right
None
by
Adams Test: Lumbar/T-L (deg)
L/R
Left
Right
Adams Test: Thoracic (deg)
L/R
Left
Right
Adams Test: Prox. Th. (deg)
L/R
Left
Right
Decompensation:
L/R
Left
Right
Hypokyphosis
None
Mild
Mod
Severe
Shoulder discrepancy (which lower)
Left
Right
None
by
Leg length discrepancy (which lower)
Left
Right
None
by
Compliance
High
Mod
Low
Pt meas/casted today
Yes
No
Stretching Instruction given:
Y
N
On hold pending approval
Yes
No
Next appt in approx
Practitioner Email
*
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