CLUBFOOT DATABASE STUDY
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CLINIC INTAKE FORM
Please note that the following information will be kept completely confidential and will not affect your child’s care in any manner. Please answer the questions to the best of your ability and feel free to ask any questions. Thank you!
Today’s Date: _______________
Your Child’s Information:
________________________________________
Last Name, First Name, Middle Name Past Medical History
Problems during pregnancy or birth (please specify) ________________
Developmental problems (please specify) _________________________
Heart problems (please specify) _______________________________
Frequent infections (please specify) ____________________________
Traumatic Injury (please specify) ______________________________
Other (please specify) _______________________________________
Past Surgical History
_______________________________ ____________
Procedure Date
_______________________________ ____________
Procedure Date
_______________________________ ____________
Procedure Date
____/_____/_________
Date of Birth
Primary Guardian
_________________________________________________
Last Name, First Name ________________________
Relation to Child
______/______/________ ___________
Date of Birth Age
_____________________________________________
Primary Address Line 1
_____________________________________________
Primary Address Line 2
_____________________________________________
City, State Zip
(_______)___________________________
Phone
____________________________________
Other Guardian (if applicable)
_________________________________________________
Last Name, First Name ________________________
Relation to Child
______/______/________ ___________
Date of Birth Age
_____________________________________________
Primary Address Line 1
_____________________________________________
Primary Address Line 2
_____________________________________________
City, State Zip
(_______)___________________________
Phone
____________________________________
CLUBFOOT DATABASE STUDY
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How satisfied are you with the brace?
Extremely Very satisfied Neutral Unhappy Very unsatisfied
What brace wearing schedule has your doctor recommended?
___________________________________
___________________________________
___________________________________
By your best guess, how many hours per day does your child wear the brace?
___________________________
Compared to your doctor’s recommendations, how often does your child wear the brace?
Never
Rarely (<20% of time recommended) Some of the time
Most of the time (>80% of time recommended) Always
Only when sleeping
Other ___________________
For what reasons does your child NOT wear the brace? (Mark all that apply)
Child’s discomfort or pain Child not able to move
Difficulty in putting on or taking off brace Forgot
Unsure of instructions Does not seem to work Too busy, vacation
Other ____________________________
_____________________________
Who is the primary caretaker of the child?
Both parents Mother Father
Family member (please specify)_________
Other (please specify) _________________
Who else helps with the care of the child? (Mark all that apply)
Mother Father Grandparent Sibling
Family member (please specify) ____________
Other (please specify) ____________________
Child’s Ethnicity (check all that apply) White
Black Hispanic
Asian/Pacific Islander Native American Other _____________
Level of Education – Primary caregiver less than 9th grade
9th to 12th grade, no completion High school or equivalent completed Some college, no degree
Associate or Bachelor’s degree Postgraduate or Masters degree Professional or Doctorate Degree Household Annual Income (approximate)
less than $20,000 / year $20,000 to 40,000 / year $40,000 to 60,000 / year $60,000 to 80,000 / year $80,000 to 100,000 / year > $100,000 / year
Please leave any additional comments here:
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