Please take a few minutes to complete the following questions, so we may better serve you or your child.



2. Is your (or your child) Pectus Excavatum (depression) getting worse?

Or Pectus Carinatum (protrusion) getting worse?


3. If you answered Yes to question 2, over what amount of time have you notice your (or child) condition worse?
Check one:



5. What other symptoms have you noticed (or your child)?


Explain:


Explain:



Explain:


6. Do others in your family, incluiding extended family have Pectus Excavatum?
If Yes, please explain the family relationship:


7. Do others in your family, incluiding extended family have Pectus Carinatum?
If Yes, please explain the family relationship:


8. Is there a family history of: Marfan's syndrome?
Ehlers-Danlos syndrome?


9. Any allergy to metal?
If Yes, please explain:


10. Do you have (or your child) x-rays taken? [not older than 6months]
If yes, please send an email or share by Google Drive or Dropbox copies of those studies or scans. (jpg, jpeg, tiff, or DICOM files)


11. Do you have (or your child) a cardiology evaluation? [not older than 6months]
If yes, please send an email or share by Google Drive or Dropbox copies of those reports. (jpg, jpeg, tiff, doc or DICOM files)


12. Do you have (or your child) pulmonary function test? [not older than 6months]
If yes, please send an email or share by Google Drive or Dropbox copies of those reports. (jpg, jpeg, tiff, doc or DICOM files)


13. Have you (or your child) ever had bracing therapy?
If yes, please complete below

Bracing system brand:

Duration of bracing therapy:

Have you noticed any changes with the use of the brace?


*Please confirm that all your data is correct before sending, thanks!