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Scoliosis Form
Date:
Last Name:
First Name:
Social Security #:
When was the spinal curvature first noted?
Who first noticed the curvature?
Has the curve gotten worse over time?
No
Yes
What sort of treatment have you had to date?
None
If you have had scoliosis surgery, when, where, and who performed the procedure?
Is there pain in your back? If so, where is the pain and when do you feel it?
Is there any weakness in your legs?
No
Yes
__________________________________________________________________________________________________________________________________________________________
Skip this section if you have no pain or weakness
What makes your pain worse?
Sitting
Standing
Walking
Bending Forward
Bending Backward
Coughing
Sneezing
Nothing
What reduces your pain?
Sitting
Standing
Walking
Medication
Exercise
Lying Down
__________________________________________________________________________________________________________________________________________________________
What diagnostic tests have you had?
X-Rays
MRI
Myelogram
CT Scan
Discogram
Bone Scan
None
For Girls/Women - Have you started menses (menstrual cycles):
No
Yes
If yes, Age when started?
Have they been regular?
No
Yes
Sudents: Please state your school and grade
Are you working?
No
Yes
Occupation:
How many days, if any, have you missed from work in the past year due to back pain?
Do you smoke?
No
Yes
If yes, how many packs per day?
How many years?
Do you drink alcoholic beverages?
No
Yes
Do you now, or have you ever taken illicit drugs?
No
Yes
Is there a family history of scoliosis?
No
Yes
If so, who?
How tall is your biological mother?
Father?
Siblings (Age and Height)
Neurologic Disease?
No
Yes
If yes, what type?
What other medical problems do you have or have you had?
Asthma
Arthritis
Angina
High Blood Pressure
Stroke
Spinal Bifiba
Cerebral Palsy
Ulcers
Kidney Disease
Liver Disease
Hepatitis
Diabetes
Tuberculosis
Muscular Dystrophy
Other
If other, what?
Please list any surgery, other than scoliosis surgery, that you have had:
Please list any medication you are taking at this time:
If you are allergic to any medications please list them below:
Latex allergy?
Yes
No
__________________________________________________________________________________________________________________________________________________________
Parent/Guardian Signature:
*
clear
Phone Number:
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