Scoliosis TodayInitial Evaluation S & D : YesNo MAB YesNo Patient Name (*) D.O.B. (*) Date of Exam (*) Delivery Date _______________________________________________________________________________________________________________________________________ Referring M.D: (*) Orthotist (*) Orthotist e-mail (*) _______________________________________________________________________________________________________________________________________ Transfer Pattern Brace Type (*) Full TimePart TimeNight TimeProvidence _______________________________________________________________________________________________________________________________________ Height(*) cmftin Weight(*) kglb Age (*) Gender(*) MaleFemale Menarche(*) PrePostN/A Voice change(*) YesNoN/A Months _______________________________________________________________________________________________________________________________________ Pt's first orthosis? (*) YesNo Risser (*) 012345N/A Sanders (*) 12345678N/A _______________________________________________________________________________________________________________________________________ Shoulders level? YesNo Higher side? RightLeft _______________________________________________________________________________________________________________________________________ Pelvis level? YesNo Higher side? RightLeft _______________________________________________________________________________________________________________________________________ Shoe lift? YesNo Shoe side? RightLeft _______________________________________________________________________________________________________________________________________ Truncal decomp? YesNo Truncal side? RightLeft Distance _______________________________________________________________________________________________________________________________________ ATR Prox Thoracic RightLeft Thoracic RightLeft T-R-L RightLeft Lumbar RightLeft _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ Chest Circumferene ML AP ST Notch _______________________ Xyphoid Circumferene ML AP Nip S. Scap. Axila _______________________ Waist Circumferene ML AP Prox Trim L. Inf. Scap. R. Inf. Scap. Lateral Trim _______________________ I.C. Circumferene ML AP ASIS Distal Trim _______________________ ASIS Circumferene ML AP _______________________ Troch Circumferene ML AP Pubis _______________________ ASIS to ASIS _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ Curve type _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ Proximal(C4 to T4) L.Cobb º (0 to 100) ATR º (0 to 25) Apex —Please choose an option—C4C4-C5C5C5-C6C6C6-C7C7C7-T1T1T1-T2T2T2-T3T3T3-T4T4 R.Cobb º (0 to 100) ATR º (0 to 25) Thoracic(T4 to T12) L.Cobb º (0 to 100) ATR º (0 to 25) Apex —Please choose an option—T4T4-T5T5T5-T6T7T7-T8T8T8-T9T9T10-T11T11T11-T12T12 R.Cobb º (0 to 100) ATR º (0 to 25) T Lumbar(T11 to L2) L.Cobb º (0 to 100) ATR º (0 to 25) Apex —Please choose an option—T11T11-T12T12T12-L1L1L1-L2L2 R.Cobb º (0 to 100) ATR º (0 to 25) Lumbar(L1 to L5) L.Cobb º (0 to 100) ATR º (0 to 25) Apex —Please choose an option—L1L1-L2L2L2-L3L3L3-L4L4L4-L5L5 R.Cobb º (0 to 100) ATR º (0 to 25) _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ PMH : HPI : Additional Notes: _______________________________________________________________________________________________________________________________________ Δ
