Clubfoot Radiographic Evaluation Form
Document findings and impressions for a clubfoot radiographic assessment using this standardized form.
Patient/Case Identifier
*
Evaluation Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Age (years)
*
Side Evaluated
*
Left
Right
Bilateral
Radiograph View(s) Obtained
*
AP
Lateral
AP and Lateral
Other
Clubfoot Severity / Baseline Findings
*
1
2
3
4
5
Hindfoot Alignment
*
Varus
Neutral
Valgus
Not Assessed
Midfoot Alignment
*
Adducted
Neutral
Abducted
Not Assessed
Ankle Dorsiflexion on Imaging (degrees)
*
Interpretation / Impression
*
Submit Evaluation
Should be Empty: