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Scoliosis Screening Program Referral/ Order Form 404-785-7553 Fill out form and FAX to: 404-785-7576 Date: To be filled out by Scoliosis Screening Program Clinic Site Clinic Date Patient Name: Date

How to fill out scoliosis screening program referral

To fill out a scoliosis screening program referral, follow these steps:

1. Begin by filling out the patient's personal information, including their full name, date of birth, address, and contact number. This information is crucial for identification purposes.
2. Next, provide the patient's medical history. Include any previous diagnoses, surgeries, allergies, and current medications. This information helps healthcare professionals understand the patient's overall health and potential risk factors.
3. Indicate the reason for the referral as "Scoliosis Screening Program." This ensures that the healthcare provider knows the purpose of the referral and can schedule the appropriate tests and screenings.
4. Specify any symptoms or concerns that led to the referral. For example, if the patient has reported back pain, difficulty standing or walking, or a noticeable spinal curvature, mention these in the referral. This information helps healthcare professionals prioritize the urgency of the screening.
5. Include any relevant family history. Since scoliosis can have a genetic component, it is essential to provide details about any family members who have been diagnosed with scoliosis or have a history of spine-related issues.
6. If available, attach any recent medical imaging or test results that may aid in the screening process. This could include X-rays, MRIs, or CT scans. These documents can provide additional information for the healthcare provider.

Who needs a scoliosis screening program referral?

A scoliosis screening program referral is typically needed for individuals who meet certain criteria or display potential signs of scoliosis. These may include:

1. Children and adolescents: Scoliosis is commonly detected during growth spurts in children and teenagers. Regular screenings are often recommended for this age group, especially if there is a family history of scoliosis or the child exhibits symptoms such as back pain or an abnormal posture.
2. Individuals with known risk factors: People with specific risk factors, such as a family history of scoliosis, certain connective tissue disorders, or neuromuscular conditions, may require regular screenings to monitor their spinal health.
3. Those presenting symptoms: If an individual experiences symptoms such as back pain, muscle weakness or imbalance, or a visible spinal curvature, a scoliosis screening may be necessary to evaluate their condition and determine appropriate treatment options.
4. Post-surgical patients: Individuals who have previously undergone spinal surgeries or treatments for scoliosis may need regular follow-up screenings to monitor their progress and ensure the condition does not reoccur.

It is important to consult with a healthcare provider to determine if a scoliosis screening program referral is necessary based on the individual's unique circumstances and medical history.

For pdfFiller’s FAQs

What is scoliosis screening program referral?

A scoliosis screening program referral is a form completed by healthcare providers to refer individuals for further evaluation for scoliosis.

Who is required to file scoliosis screening program referral?

Healthcare providers are required to file scoliosis screening program referral for individuals who may need further evaluation for scoliosis.

How to fill out scoliosis screening program referral?

To fill out a scoliosis screening program referral, healthcare providers must provide the necessary information about the individual being referred and indicate the reason for the referral.

What is the purpose of scoliosis screening program referral?

The purpose of scoliosis screening program referral is to ensure that individuals at risk for scoliosis receive timely evaluation and treatment.

What information must be reported on scoliosis screening program referral?

The scoliosis screening program referral must include the individual's medical history, physical examination findings, and any relevant imaging studies.

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