Please  bring this form with you to your appointment, do not drop it off beforehand

                           Pediatric & Adolescent Scoliosis/Kyphosis Questionnaire

Only fill out this form if you are seeing the doctor for Scoliosis or Kyphosis. Please fill out this form completely and neatly.  If you have any questions, please ask the nurse.

DATE _______  PATIENT NAME________________________  Date of Birth _________

Developmental History:

            Birth:    Premature x  ______ wks  or    Normal time

            Problems at birth:  

Approximate  Height ______________            Weight _______________

Approximate growth in last 6 months________________

Height of mother ___________   Height of father  ____________  

Height of siblings _______________________________

How was scoliosis/kyphosis discovered? _____________________

Previous treatment for scoliosis/kyphosis _____________________

Have menses/periods begun?   YES/NO    Approximate date begun _____________

Are your menses/periods regular?  YES/NO

Previous surgeons seen for treatment of scoliosis/kyphosis _____________________