Visit		1st Visit		2nd Visit		3rd Visit		4th Visit		5th Visit		6th Visit		7th Visit		8th Visit		9th Visit
Date
Child Not Walking Pirani Score
Foot		L	R	L	R	L	R	L	R	L	R	L	R	L	R	L	R	L	R
CLB
MC
LHT
MFS
PC
RE
EH
HFS
TS

Child Walking PBS Score
Foot		L	R	L	R	L	R	L	R	L	R	L	R	L	R	L	R	L	R
HR
PAD
AAD
PBSA
HV
SS
WS
SA
PBSS
PBST

Follow Up
Diagnosis (1-9)		L	R	L	R	L	R	L	R	L	R	L	R	L	R	L	R	L	R
Treatment (P,T,FAB,O,R,S,D)
Cast position (#1-5)
FAB Use (Y/N/N/A)
FAB Use (hours/day)
FAB Size (# 3-14)
Complication (P,I,C,O,N)
Diagnosis: 1= Syndromic; 2= Untreated Walking; 3= Untreated not walking; 4= Atypical; 5= Post-surgical; 6= Complex; 7= Persistent; 8= Well corrected; 9= Unaffeced (of unilateral clubfoot)
Treatment: P= Ponseti Cast; T= Tenotomy; FAB= Foot Abduction Brace; O= Observation; R= Referred for surgery; S= Skin care for pressure area/infection; D= Discharge
Complication: P= Pressure Score; I= Infection; C= Cast Slip; O= Other; N= None