Run Scoliosis and Postural Screening Log and Parent Referral Notice — Free

Screening Event Identification

School name and campus location recorded critical (required)

Screening date documented critical (required)

Note (optional)

Student name or unique student ID recorded critical (required)

Grade level documented critical (required)

Note (optional)

Screener name and role documented critical (required)

Screening Conditions and Student Preparation

Private or appropriate screening area used critical (required)

Yes No N/A

Student wore appropriate clothing for postural observation critical (required)

Yes No N/A

Student was able to stand and follow screening instructions critical (required)

Yes No N/A

Screening deferred or rescheduled due to illness, injury, or other limiting condition

Yes No N/A

Postural Screening Observations

Head and neck alignment appeared symmetrical critical (required)

Yes No N/A

Shoulder height appeared symmetrical critical (required)

Yes No N/A

Scapular prominence or trunk asymmetry observed critical (required)

Yes No N/A

Waistline or hip level appeared symmetrical critical (required)

Yes No N/A

Forward bend test completed when indicated by screening protocol

Yes No N/A

Any visible postural abnormality documented

Referral Determination and Parent/Guardian Notice

Screening result recorded as pass, rescreen, or referral critical (required)

Note (optional)

Parent/guardian referral notice issued when referral criteria were met critical (required)

Yes No N/A

Referral notice date documented critical (required)

Note (optional)

Referral notice method documented critical (required)

Note (optional)

Follow-Up, Documentation, and Sign-Off

Follow-up instructions or next steps documented

Any referral packet, screening form, or parent notice attached to record

Yes No N/A

Inspector or screener signature completed critical (required)

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Run: Scoliosis and Postural Screening Log and Parent Referral Notice

Screening Event Identification

Screening Conditions and Student Preparation

Postural Screening Observations

Referral Determination and Parent/Guardian Notice

Follow-Up, Documentation, and Sign-Off

Get your results