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