Pectus Patient Evaluation

Date:

Patient's full name:

Parent's name:

E-mail:

1. What is the main reason you are looking for medical / surgical evaluation for You or your child?

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

Or Pectus Carinatum (protrusion) getting worse?
YesNo

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

4. How old were you (or your child) when you notice the depression?

Or protrusion?

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

Exercise intolerance, i.e. inability to do sports for regular or prolonged times.
Explain:

Lack of endurance, i.e. needs to stop for rest or to catch your breath during tireless activities.
Explain:

Chest painShortness of breathNeed to change or modify physical activityProlonged respiratory tract infectionsPalpitationsAnxietyChest pain while exercisingShortness of breath while exercisingFrequent respiratory tract infectionsAsthma or asthma like symptomsScoliosis (column deviation)Discomfort with physical appearanceOther?

Explain:

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

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

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

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

10. Do you have (or your child) x-rays taken? [not older than 6months] YesNo
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] YesNo
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] YesNo
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? YesNo
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!