Scoliosis Radiographic Evaluation Form
Use this form to collect the information needed for scoliosis radiographic evaluation and image review before or during an imaging visit.
Patient and Referring Details
Patient Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex Assigned at Birth
Please Select
Female
Male
Intersex
Prefer not to say
Other
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Email
example@example.com
Referring Clinician Name
*
First Name
Middle Name
Last Name
Clinic or Hospital Name
*
Scoliosis History and Symptoms
Reason for evaluation
*
Known scoliosis diagnosis status
*
Yes
No
Unsure
Age at diagnosis (if known)
Curve location (if known)
Please Select
Thoracic
Lumbar
Thoracolumbar
Double curve
Unknown
Prior scoliosis treatment history
Observation
Brace
Physical therapy
Surgery
None
Presence of back pain
*
Yes
No
Pain severity
1
2
3
4
5
Mobility/function impact
No impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is No impact, 10 is Severe impact
Neurologic symptoms
Numbness
Weakness
Gait issues
None
Symptom onset or changes
Prior Imaging and Current Radiographic Request
Pre-Imaging Safety Check
Pregnancy status
*
Not applicable
No, not pregnant
Yes, pregnant
Unsure
Imaging safety screening
*
Metal implants or hardware
Unable to remove metal objects
Recent contrast study
Other safety concern
Submit
Should be Empty: