Clubfoot Assessment Survey
Please complete this survey to help us assess the status and progress of clubfoot treatment. Your responses are valuable for clinical evaluation and ongoing care.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email Address
*
example@example.com
Who is completing this survey?
*
Parent/Guardian
Patient (self)
Clinician/Healthcare Provider
Other
Which foot is affected by clubfoot?
*
Left
Right
Both
How would you rate the severity of the clubfoot currently?
*
Mild
1
2
3
4
Severe
5
1 is Mild, 5 is Severe
Age at Diagnosis (in months)
*
Previous Treatments Received (select all that apply)
Ponseti casting
Surgical intervention
Physical therapy
Bracing
Other
Current Clinical Findings
*
Rows
Range of Motion
Muscle Strength
Foot Position
Pain
Excellent
1
2
3
4
Good
5
6
7
8
Fair
9
10
11
12
Poor
13
14
15
16
How much pain or discomfort does the patient experience due to clubfoot?
*
None
0
1
2
3
4
5
6
7
8
9
Severe
10
0 is None, 10 is Severe
How does clubfoot affect the patient's daily activities?
*
No impact
Mild impact
Moderate impact
Severe impact
How satisfied are you with the current treatment outcome?
*
1
2
3
4
5
Additional Comments or Concerns
Submit Assessment
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