Healthcare Scoliosis Care Plan

Healthcare Scoliosis Care Plan

Patient Information

Insurance & Responsible Party

Medical History & Examination

Curve location(s): Lumbar / Thoracic / Thoracolumbar (circle/all that apply). Primary curve: . Cobb angle measurement (primary): . Secondary curve Cobb angle: .

Skeletal maturity (Risser): . Scoliometer or rotation: . Pain level (0–10):

Care Plan — Interventions & Schedule

The following interventions are recommended based on current clinical assessment. Select all that apply and provide specific instructions below.

Observation with periodic clinical and radiographic monitoring
Custom spinal orthosis (bracing)
Physical therapy (conservative scoliosis program)
Prescribed home exercise program
Referral for surgical consultation (if indicated)
Pain management / multimodal interventions

Follow-up schedule: First follow-up in , then every or as clinically indicated.

Risks, Benefits, and Alternatives

I acknowledge that the proposed care plan has potential benefits, including slowing curve progression, reducing pain, and improving function. I understand risks may include discomfort from bracing, skin irritation, temporary increase in pain with exercise, progression of curvature despite conservative measures, and, if surgical referral is required, risks associated with operative intervention including infection, neurological injury, failure of instrumentation, and need for revision surgery. There is no guarantee of complete correction.

Alternatives to the selected interventions include continued observation, modification of activity, alternative physical therapy approaches, or proceeding to surgical review. The patient retains the right to decline or withdraw consent to any portion of the care plan at any time, except to the extent that treatment has already been provided.

Consent, Authorization, and Release

By checking the box below and signing, I authorize the clinical team to implement the scoliosis care plan described in this document. I authorize clinicians to perform routine examinations, obtain and review radiographs, fit or order orthotic devices, provide physical therapy, and communicate with my insurance carrier and other providers as necessary for care coordination and payment. I understand that photographs, radiographs, and treatment notes related to my care may be used for my clinical record and may be shared with consulting providers when clinically necessary.

I consent to the Scoliosis Care Plan and authorize the indicated care interventions.

Authorization expiration date:

Privacy & HIPAA Acknowledgment

I acknowledge that I have been advised of the clinic's privacy practices and that my protected health information will be handled in accordance with applicable privacy laws. I understand my rights to request restrictions, confidential communications, and amendments to my record in accordance with policy and law.

I acknowledge the privacy practices and authorize necessary communications regarding scheduling, billing, and clinical care.

Provider / Care Team

Administrative Acknowledgments

I understand that any modification to this plan should be documented in writing by the treating clinician. I accept responsibility to follow home programs and attend scheduled follow-up visits. Failure to follow the plan may affect outcomes and will be documented in my medical record.

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