Newborn Sacral Dimple Evaluation Form
Complete this form to document and assess sacral dimples in newborns for risk stratification and follow-up.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Name
*
First Name
Last Name
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Physical Examination Findings
*
Rows
Normal
Abnormal
Midline dimple
1
2
Visible base
3
4
Tuft of hair
5
6
Skin discoloration
7
8
Hemangioma
9
10
Discharge
11
12
Dimple Location
*
Within 2.5 cm of anus
Above 2.5 cm from anus
Associated Symptoms
Abnormal lower limb movement
Abnormal urinary or bowel function
Other (please specify)
Family History of Spinal Abnormalities
Yes
No
Unknown
Imaging or Specialist Referral Recommended?
*
No further action needed
Ultrasound recommended
MRI recommended
Neurosurgery referral
Additional Comments
Submit Evaluation
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