Register Preschool Screening Registration DOB *: Does your child ever complain of pains in the legs? YesNo Are you ever concerned about your child’s posture? YesNo Do you notice your child tripping over or seeming clumsy when walking? YesNo Do you feel your child is not keeping up physically with his/her peers? YesNo Does your child not want to walk? YesNo Does your child suffer from growing/night pains? YesNo How Often? N/ADailySeveral times a weekWeeklyMonthlyIrregular Do you worry about the way your child walks (eg. in-toeing/flat feet)? YesNo Do your child’s shoes wear unevenly? YesNo Does your child seem reluctant to participate in sport or other activities? YesNo I give permission for a representative of A Step Ahead Foot + Ankle Care to perform a foot screening on my child. I understand that A Step Ahead Foot + Ankle Care will send a report directly to the address or email address provided, and, in addition, I may be contacted about the report. Sign here [signature* signature-391]
