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

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