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Run: Scoliosis and Postural Screening Log and Parent Referral Notice

Track scoliosis and postural screening results, document observable asymmetry, and record parent/guardian referral notices in one school-ready log. Use it to...

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Screening Event Identification

School name

Screening date

Screener name and role

Grade level

Screening Conditions and Student Preparation

Appropriate clothing for postural observation

Yes No N/A

Student able to stand and follow instructions

Yes No N/A

Screening deferred due to illness, injury, pain, or limited mobility

Yes No N/A

Postural Screening Observations

Shoulder height difference (mm)

Scapular prominence difference (mm)

Waistline or hip level asymmetry (mm)

Rib hump on forward bend (mm)

Forward bend test performed

Yes No N/A

Referral Determination and Parent/Guardian Notice

Screening result

Parent/guardian notice method

Parent/guardian notice date

Follow-up instructions or attachments provided

Yes No N/A

Follow-Up, Documentation, and Sign-Off

Completed form reviewed and signed

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