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PHYSICAL ASSESSMENT/VITAL SIGNS
In the delivery of health services, every patient deserves a general survey at every encounter with a health care provider. A general survey may be described as an overall review or first impression that the health care provider has of a person’s well being. This could be as simple as a visual observation and encompasses the following examples and components dependent to some extent on age.
• Appearance – appears stated age; sexual development appropriate; alert, oriented; facial features symmetric; no signs of acute distress
• Body structure/mobility – weight and height within normal range; body parts equal bilaterally; stands erect, sits comfortably; walk is smooth and well balanced; full mobility of joints
• Behavior – maintains eye contact with appropriate expressions; comfortable and cooperative with examiner; speech clear; clothing appropriate to climate; looks clean and fit; appears clean and well groomed
Deviations from what would generally be considered to be normal or expected should be documented and may require further evaluation or action.
Information about audiometric screening and the Snellen Test for vision screening are covered in this section.
A patient history should be done as indicated by the age specific Preventive Health Guidelines.
A comprehensive history (including chief complaint or reason for the visit, a complete review of systems and a complete past family and/or social history) should be obtained on the first preventive health visit by the physician, advanced registered nurse practitioner, physician assistant or nurse. The history should be age and sex appropriate and include all the necessary questions to enable an adequate delivery of services according to the Preventive Health Services and/or the patient’s need, visit requirement, Health Guidelines, or request. The completion of the history component of the Health History and Physical Examination Form will assist in the assessment of the patient’s past and current health and behavior risk status. Certain health problems, which may be identified on a health history, are more common in specific age groups and gender. These may be found in the Preventive Health Guideline section as things for which to be alert.
An interval history (including an update of complaints, reason for visit, review of systems and past family and/or social history) should be done as indicated or as identified on the age specific Preventive Health Guidelines.
Completion of all items on the history component of the Interval Health History and Physical Examination Form will give a picture of the patient’s current health and behavior risk status. Additional information may be required depending on the specialized service(s) to be provided.
Guidelines for other than preventive health visits will indicate the components of history appropriate for the presenting special need or conditions. The level of history indicated may be problem focused, expanded problem focused, detailed, or comprehensive. Depending upon the level of history obtained, documentation may be on the history portion of the Health History and Physical Examination form or in the service notes, but some notation must be recorded for each visit.
A comprehensive or partial physical examination should be done at appropriate intervals by appropriate staff, and according to the age specific preventive health guidelines for services. The 1994 AMA Guidelines recognize the following body areas and organ systems for purpose of the examination:
Body Areas: Head (including the face); Neck; Chest (including breasts and axillae); Abdomen; genitalia, groin, buttocks; Back (including spine); and each extremity.
Organ Systems: Constitutional (vital signs, general appearance), Eyes, Ear, Nose, Throat; Cardiovascular; Gastrointestinal; Genitourinary; Musculoskeletal; Dermatological; Neurological; Psychiatric; Hematological/lymphatic/immunological.
1996 AMA guidelines recognize only a multisystem exam or body areas. At present, either is acceptable for use. When a comprehensive physical examination is indicated on the schedule, the physical examination component on the forms should be completed in its entirety to document the assessment of all body areas and organ systems, as appropriate to the individual’s age and medical history. Normal and abnormal findings and pertinent negatives should be recorded.
The examination appropriate for other than preventive services may be problem focused, expanded problem focused, detailed or comprehensive. Except for a comprehensive exam, the pertinent findings may be documented on the Health History and Physical Examination forms.
Certain health problems, which may be identified on a physical examination, are more prevalent in specific age groups and gender. These will be found in the Preventive Health Guidelines as something for which to be alert.
Body measurements include length or height, weight, and head circumference for children from birth to 36 months of age. Thereafter, body measurements include height and weight. The assessment of hearing, speech and vision are also measurements of an individual’s function in these areas. The Denver Development assessment is a tool to measure an infant’s and young child’s gross motor, language, fine motor-adaptive and personal-social development. If developmental delay is suspected based on an assessment of a parent’s development/behavior concern or if delays are suspected after a screening of development benchmarks, a written referral is made to a Physician or First Steps for further evaluation. Other developmental tools include the developmental screen; benchmarks in the Pediatric Preventive Guidelines may be used.
A patient’s measurements can be compared with a standard, expected, or predictable measurement for age and gender. The Body Mass Index (BMI) chart in this section applies to adults. Age and gender appropriate growth charts in the Forms Section apply to children. Deviation from standards helps identify significant conditions requiring close monitoring or referral.
The significance of measurements and actions to take when they deviate from normal expectations are found in the age-specific Preventive Health Guidelines.
Obtain height by measuring the recumbent length of children less than 2 years of age and children between 2 and 3 who cannot stand unassisted. A measuring board with a stationary headboard and a sliding vertical foot piece shall be used. Lay the child flat against the center of the board. The head should be held against the headboard by the parent or an assistant and the knees held so that the hips and knees are extended. The foot piece is moved until it is firmly against the child’s heels. Read the measurement to the nearest 1/8 inch.
Obtain a standing height on children greater than 2 to 3 years of age, adolescents, and adults. Measurements may be accurately made by using a graduated ruler or tape attached to the wall and a flat surface that is placed horizontally on top of the head. The patient is to be wearing only socks or be bare foot. Have the patient stand with head, shoulder blades, buttocks, and heels touching the wall. The knees are to be straight and feet flat on the floor, and the patient is asked to look straight ahead. The flat surface (or moveable headboard) is lowered until it touches the crown of the head, compressing the hair. A measuring rod attached to a weight scale shall not be used.
If recumbent length is obtained for a two year old, it is plotted on the birth to 36 months growth chart, whereas, if standing height is obtained for a two year old, plot on the 2 to 18 year growth chart. Plot measurements for children on age and gender specific growth charts and evaluate accordingly.
Balance beam or digital scales are to be used to weigh patients of all ages. Spring type scales are not acceptable. CDC recommends that all scales should be zero balanced and calibrated. Scales must be checked for accuracy on an annual basis and calibrated in accordance with manufacturer’s instructions. Prior to obtaining weight measurements, make sure the scale is “zeroed”. Weigh infants wearing only a dry diaper or light undergarments. Weigh children after removing outer clothing and shoes. Weigh adolescents and adults with the patient wearing minimal clothing. Place the patient in the middle of the scale. Read the measurement and record results immediately. Scales should be calibrated annually. Plot measurements on age and gender specific growth charts (see Forms Section) and evaluate accordingly
Body Mass Index:
The Body Mass Index (BMI) is a measure that can help determine if a person is at risk for a weight-related illness. Instructions for obtaining the BMI are included within the chart in this section for adults. To calculate BMI for children, see BMI Tables for Children and Adolescents for guidance.
Obtain head circumference measurement on children from birth to 36 months of age by extending a non-stretchable measuring tape around the broadest part of the child’s head. For greatest accuracy, the tape is placed three times, with a reading taken at the right side, at the left side, and at the mid-forehead, and the greatest circumference is plotted. The tape should be pulled to adequately compress the hair.
Vital signs, generally described as the measurement of temperature, pulse, respirations and blood pressure, give an immediate picture of a person’s current state of health and well being. Normal and abnormal ranges with management guidelines follow for children and adults.
|Move across the row until you find the weight. The number at the top of the column is the BMI. | |
| | | |
|(Birth to 10) |Newborn 100–170 |The procedure for measuring a child’s |
|Temperature between 99.8–100.8 F is considered |6 months–1 year 90–130 |respiratory rate is essentially the same as |
|low-grade fever. If the temperature is taken |2–3 years 80–120 |for an adult. However, keep in mind these |
|rectally, a temperature is not considered a fever |4–5 years 70–110 |points. |
|until it is above 100.4 |10 years–Adult 60–100 | |
|Temperature between 101–102 is considered a mild | |Since a child’s respiration rate is |
|fever. |Management |diaphragmatic, observe abdominal movement to |
|Temperature between 102–103 is considered a moderate|The apical heart rate is preferred in children. |count the respiration rate. |
|fever. |To count the rate, place stethoscope on the |Abdominal movement in a child will be |
|Temperature around 104 or above is considered a high|anterior chest at the fifth intercostal space in |irregular. |
|fever, and delirium or convulsions may occur. |a midclavicular position. Each “lub-dub” sound |Count for one full minute. |
|(11 Years to Adult) |is one beat. Count the beats for one full | |
|Temperature above 100.4 is considered a fever. |minute. While counting the rate, note whether |Normal Respiration Rate |
|If temperature is taken rectally, it would register |the rhythm is regular or irregular. |(Birth through Adult) |
|one degree higher and a reading of 101 would be | | |
|considered a fever. |Pulse rates may be checked at sites other than |Newborn 30–80 |
|Temperature between 101–102 is considered a mild |the apex, for example, the carotid, brachial, |6 months 24–36 |
|fever. |radial, femoral, and dorsal pedis sites. Compare|1 year 20–40 |
|Temperature between 102–103 is considered a high |the distal and proximal pulses for strength. |2–3 years 20–30 |
|fever, and delirium or convulsions may occur. |Also record whether the pulse is normal, bounding|4–6 years 16–22 |
|Management |(very strong), or thready (weak). |6–10 years 16–20 |
|Assess the patient to determine if other signs or | |11–20 years 12–20 |
|symptoms are present (i.e., flushed face, hot, dry |When reviewing the resting heart or pulse rate in| |
|skin, low output and highly concentrated urine, |each of the age groups, if the rate is not within| |
|disinterest in eating, constipation, diarrhea, or |the normal limits: | |
|vomiting. Older children or adolescents may |Repeat to confirm. | |
|complain of sore throat, headaches, aching all over,|Review history for appropriate age group to | |
|nausea, constipation, or diarrhea). |determine if patient is taking medication that | |
|Determine if elevated temperature could be post |may alter the heart rate or if the patient is | |
|immunization (see Immunization Section), or related |active in sports or exercise programs (i.e., | |
|to underlying condition, being treated at the LHD. |runner, jogger, football, basketball, tennis, | |
|If not, seek medical consultation and/or refer for |etc.). | |
|medical evaluation. |If heart or pulse rate is outside the normal | |
|Fever in an infant 3 months and younger is of |range and there is no appropriate rationale, | |
|greater significance and medical consultation or |refer for medical evaluation. | |
|referral should occur. | | |
BLOOD PRESSURE READINGS IN CHILDREN
Blood pressure measurement for a child is basically the same as for an adult. The size of the blood pressure cuff is extremely important. Whether manual or electronic equipment is being used, the size of the blood pressure cuff is determined by the size of the child’s arm or leg. Generally, the width of the bladder cuff is two thirds of the length of the long bone of the extremity on which the blood pressure is taken. The length of the bladder cuff should be about three-fourths the circumference of the extremity and should not overlap. If the bladder of the cuff is too small, the pressure will read extremely high; if it is too large, the pressure will be falsely low.
|Age |*Normal |**Stage I |**Stage II |**Stage III |
| | |Mild Hypertension |Moderate |Severe Hypertension |
| | | |Hypertension | |
|3–5 Years |For results above normal, follow Stage II guidelines |
| Systolic |107–111 | |112 | |
| Diastolic |61–70 | |71 | |
|6–9 years | | | | |
| Systolic |111–115 |116–121 |122–129 |>129 |
| Diastolic |61–70 |71–77 |78–85 |>85 |
|10–12 Years | | | | |
| Systolic |112–116 |117–125 |126–133 |>133 |
| Diastolic |64–75 |76–81 |82–89 |>89 |
|13–15 Years | | | | |
| Systolic |116–123 |124–135 |136–143 |>143 |
| Diastolic |65–76 |77–85 |86–89 |>91 |
|16–18 Years | | | | |
| Systolic |118–126 |127–141 |142–149 |>149 |
| Diastolic |70–79 |80–91 |92–97 |>97 |
|*Source: modified from National Heart. Lung & Blood |**Source: modified from the American Academy of Pediatrics |
|Institute–Bethesda, MD | |
Management for Abnormal Blood Pressure Readings
Stage I (Mild Hypertension)
1. Repeat to confirm
2. Assess for obesity and anxiety
3. Review for underlying causes, including medications, underlying illnesses, pain, etc.
4. Health education to include:
a. Basic nutrition
b. Exercise for older children and adolescents
c. Monitor weekly at 3 different times within 1 month to confirm baseline values; then monitor at routine visits.
Stage II and III (Moderate to Severe Hypertension)
1. Repeat to confirm
2. Health and nutrition education
3. Refer for medical evaluation
CLASSIFICATON AND MANAGEMENT OF BLOOD PRESSURE FOR ADULTS
Ages 18 and Older
| | | | |
|BP Classification |SBP mmHg |DBP mmHg |Management |
|Normal |100 |Prescribe lifestyle modifications. |
|Hypertension | | |Confirm hypertension in contralateral arm. |
| | | |Assess risk factors. |
| | | |Refer for medical evaluation. |
| | | |Provide or refer for medical nutrition therapy. |
Source: Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7).
PROCEDURES FOR MEASURING HEARING
(Birth to Adult)
Hearing is assessed in infants and young children (1–36 months) by observing responsiveness to 3 tones, i.e., voice, bell, rattle. (Do not use a hand held screening audiometer).
Administration of an acceptable response to:
1. Voice: with the child not facing you, stand behind the child within 6–12 inches of either ear. Place your hand between you and the child so the infant/child does not respond to feeling your breath; whisper the child’s name. Repeat with the other ear. Hearing is normal if the child turns to the direction of voice for each ear.
2. Bell and Rattle: hold the bell/rattle to the side and behind the child’s ear, ring the bell/shake the rattle softly. Try again, if no response. Repeat with the other ear. Hearing is normal if the child responds by an eye movement, change in expression, breathing rate or activity.
Hearing is assessed in children 3 years and older (depending on understanding and cooperativeness), adolescents, and adults with pure tone screening (audiometers). If unable to test the child using the pure tone screening procedure, assess the hearing as described for younger children.
The room used for hearing screening should be as quiet as possible, because background noise interferes with the accuracy of the test and leads to false positive results. Examples of background noise are hallways, fluorescent light hum, etc. The tester, who has normal hearing, may test him/herself to be sure that ambient noise does not interfere with testing. The testing room must be at least large enough to accommodate a table for the audiometer and chairs for the tester and patient. The patient’s chair should be positioned so that the patient cannot see the operation of the audiometer.
Pure Tone Screening Procedure:
1. Power: Turn on.
2. Masking: Check to insure that masking is turned off.
3. Output Selector: Red earphone is for the right ear (Hint: R for R)
Blue earphone is for the left ear.
4. Tone Level or Tone Interrupter: Normally Off. Press down to produce tone.
5. The following test levels shall be followed for these frequencies:
1 1000Hz 2000Hz 4000Hz
a. 20dB for sound proof room
b. 25dB for exam room
PROCEDURES FOR MEASURING HEARING
(Birth to Adult)
6. Patients being tested with pure tone audiometer are given verbal instructions to raise their hand when the tone is heard. Children age 6 and below may be able to raise the hand, but it is often easier to have them drop a block. Children below age 6 should have a demonstration: Place the headphones on the table or in your lap, present a tone at 90dB and raise your hand/drop a block. Repeat this having the child perform with you simultaneously. Repeat the tone, but allow the child to perform alone. TURN THE TONE BACK DOWN to 20dB, then place the headphones on the child (adolescent, adult) and proceed with the specified test levels.
1. Set frequency dial at 1000Hz.
2. Set hearing level at 20dB
3. Present the tone by pressing the tone level.
4. To be assured that the patient is responding correctly, the tone may need to be presented several times. Once the desired response is received (i.e. drop a block/raised hand), continue the test and complete the screening as follows:
a. Sound Proof Room
i. Test right ear at 1000, 2000, and 4000 Hz at 20dB.
ii. Test left ear at 1000, 2000, and 4000 Hz at 20dB.
b. Exam Room Area
i. Test right ear at 1000, 2000, and 4000 Hz at 25dB.
ii. Test left ear at 1000, 2000, and 4000 Hz at 25dB.
5. If the patient DOES NOT RESPOND to the first tone presented in the right ear at 1000 Hz at 20dB (25dB) then:
a. Increase the hearing level to 30dB (leave on right ear at 1000 Hz)
b. If no response then increase to 40dB
c. If no response then increase to 50dB
d. If no response then switch the control to the left ear and follow the same procedure, increase by 10dB and decrease by 5dB.
6. Normal hearing test per audiometer:
20dB each ear, each tone – sound proof room
25dB each ear, each tone – exam room area
a. The screening test is failed if the patient fails to hear any one tone in either ear.
b. A rescreening test should be administered in two weeks for the patient, and if the patient fails the second screening, he should be referred for proper follow-up.
PROCEDURES FOR ASSESSING VISION
METHODS OF ASSESSING VISION IN CHILDREN
In newborns, vision is tested mainly by checking for light perception by shining a light into the eyes and noting responses such as blinking, following the light to midline, increased alertness, or refusing to open the eyes after exposure to the light.
INFANTS AND YOUNG CHILDREN UP TO AGE 36 MONTHS:
Normally, children 3–4 months of age achieve the ability to fixate on one visual field with both eyes simultaneously (binocularity). One of the most important tests for binocularity is alignment of the eyes to detect nonbinocular vision or strabismus.
Two tests commonly used to detect malalignment are:
1. The corneal light reflex test (also called the red reflex gemini test). A flashlight or the light of an ophthalmoscope is shined directly into the child’s eyes from a distance of about sixteen inches. If the eyes are normal, the light falls symmetrically within each pupil. If the light falls off center in one eye, the eyes are malaligned.
2. The cover test. In the cover test, one eye is covered and the movement of the uncovered eye is observed when the child looks at a near or distant object. If the uncovered eye does not move, it is aligned. If the uncovered eye moves, a malalignment is present.
Inspection of Internal Structures
The nurse inspects the red reflex, the optic disc, the macula, and the blood vessels by performing an ophthalmic examination. In a darkened room, hold the light source at arms length, draw the child’s attention to look directly at the light. Both retinal reflexes should be red or red-orange and of equal intensity.
It is important to remember that the ophthalmoscope permits only a small area of visualization. In order to perform an adequate examination, the nurse must move the ophthalmoscope systematically around the fundus to locate each structure. The fundus derives its orange-red color from the inner two layers of the eye, the choroid and the retina, which are immediately apparent as the red reflex. A brilliant, uniform red reflex is an important sign, because it virtually rules out almost all serious defects of the cornea, aqueous chamber, lens and vitreous chamber.
Observe that the infant or child follows light or a bright colored object.
PROCEDURES FOR ASSESSING VISION
THREE YEARS AND OLDER:
Testing for Alignment of Eyes
Binocularity, as described above using the Corneal Light Test (Red Eye Reflex Gemini Test) and the cover/Uncover Eye Test are the methods used to test vision of children ages three years and older as well. Both tests are described on the previous page.
Inspection of Internal Structures
Ophthalmoscope Examination – Red Reflex Exam
AGES THREE YEARS TO ADULT:
Snellen “E” Chart or instrument vision tester, i.e. OPTEC 2000/Titmus, etc.
Supplies you will need for the Snellen Test
1. Snellen “E” Chart
2. Window card
3. Tape measure
4. Adequate lighting
5. Large symbol “E”
6. Individual eye covers (may be made with construction paper cut with rounded corners or cone paper cups) to prevent the spread of infections.
Prepare The Screening Area:
• Select location that is quiet and free from distractions.
• Select location that has light colored wall that has no glare or shadows.
• Attach Snellen “E” chart to wall so that the patient’s eye level is on the 20–foot line.
• Light intensity on chart should be 10 – 20 foot candles evenly diffused over chart.
• Cover upper and lower portion of the chart with cover cards.
• Mark exactly 20 feet of distance from chart.
Prepare The Child
• Show the child the large letter “E” so he/she is familiar with the symbol.
• A game can be made with teaching the child to point in the direction the “table legs” of the “E” are pointed so he will understand the various positions of the “E”.
• Place child in standing position at the 20-foot mark and facing the chart. A set of footprints affixed to the floor with the heels at the 20-foot mark may help the child keep the proper position.
• Teach the child to keep both eyes open during the test (when covering either eye).
PROCEDURES FOR ASSESSING VISION
• Test both eyes first, then the right eye and the left eye.
• If patient wears glasses, test with and without glasses.
• In testing one eye, occlude the other eye with an occluder or cone cup.
• Begin on the 50-foot line of the Snellen “E” Chart for 3, 4, and 5 year olds. If that line is read correctly go to the 40-foot line.
• Begin on the 40-foot line of the Snellen “E” Chart for all patients above 6 years of age. If that line is read correctly, go to the 30-foot line.
• With upper and lower portions of the chart covered, use window card to expose one symbol at a time.
• Move window card promptly and rhythmically from one symbol to another at the speed with which the patient seems to keep pace.
• In linear testing, it may be necessary to use a pointer to indicate the letter.
• Patient points with his arm or hand in the direction the legs of the “E” point.
• To pass a line the patient must see one-half, or more than half of the symbols on that line.
• Observe for signs of eye problems, i.e. tilting the head, peeking around the occluder.
• Record visual acuity (the last successful line read in the order tested), e.g. both eyes – right eye – left eye.
Record the results as a fraction – e.g. 20/30, 20/40, etc. The numerator represent the distance from the chart; the denominator represents the last line read. A reading of 20/50, for example, indicates that the child read at 20-feet the line that should be read at a distance of 50-feet. The larger the denominator is, the poorer the vision. If unable to assess vision on a three year old with the Snellen “E” Chart, counsel parent/caretaker to play the “E” game and schedule a vision screening in 3 or 4 months.
Vision acuity is assessed in the school age child, adolescent and adult by the Snellen alphabet chart or instrument vision tester. Follow the same procedure for testing both eyes, then the right eye and the left eye, occluding the eye not being tested. Begin testing with the line above the referral line and test down to the appropriate line if possible. If the patient wears glasses, test with and without glasses.
When using an instrument vision tester, follow manufacturer’s direction for vision assessment.
Snellen Test Referral Criteria for Ages 3–5
Refer children to an ophthalmologist or optometrist if visual acuity is poorer than 20/40 or poorer in either eye, if there is a two line difference between the eyes even if in passing range (i.e. 20/25, 20/40), or if signs of possible visual disturbance are present.
Snellen Test Referral Criteria for Ages 6–Adult
Refer the individual to an ophthalmologist or optometrist if visual is poorer than 20/30 in either eye if there is a two line difference between the eyes, even if in passing range (i.e. 20/20, 20/30), or if signs of possible visual disturbance are present.
Note: In accordance with KRS 200.703, Early Childhood Development, all children enrolling in the Kentucky school system must have a vision examination by an optometrist or ophthalmologist before entering school.
CONDUCTING SCOLIOSIS SCREENINGS
While not an absolute “measurement”, scoliosis screening is conducted as a part of a Preventive Health Assessment at certain ages. Using the appropriate procedure for this screening is essential and is included here for that reason.
1. Watch the child walk toward you, then turn and walk away. Notice any signs of leg length discrepancies. With back bare, the child should stand straight, feet together, looking straight ahead, arms at his/her side. Examiner will look for the following:
• Head – to see if it is centered over the pelvis (a plumb line may be helpful in checking this);
• Alignment – Does the head and base of the neck line up over the center of the sacrum?
• Shoulders – to see if they are level; (Is one shoulder higher or lower than the other side or is there a fullness on one side of the neck?)
• Scapulas (shoulder blades) – to see if one is more prominent than the other;
• Arms – to see if they are equal distance from the sides; (Is there a greater distance between the arm and flank on one side or the other?)
• Waist – to see if the indentions (waist side curves) are the same; (Is there a deeper crease over one side of the waist than the other?)
• Spine – as noted by observing the spinous processes; (Does it appear to curve?)
• Hips – to see if they are level; (Is there an asymmetrical contour of the flanks and hips?)
• The child should then bend forward with head down, the back parallel to the floor and their hands clasped; is there prominence or a bulge on one side of the back or flank?
2. View the child from the side, looking for:
• One scapula (shoulder blade) being more prominent than the other;
• Kyphosis (round back);
• Lordosis (sway back).
Any one of the findings suggests an underlying scoliosis curve, which deserves further evaluation.
The Orthopedic Systems, Inc. Scoliometer is a device that provides a way to measure the degree of rotation of a deformity of the back found on routine spinal examination. The Scoliometer is not used in place of the screening previously described, but if used in concert with the routine screening, it will provide objective guidelines for referral and also reveals small curvatures, which do not require referral, but do need rescreening.
If a deformity is suspected, the device is placed across the deformity at right angles to the body and the degree of rotation is read from the scale. The manufacturer’s recommendations should be followed regarding positive findings in need of follow-up or referral, or a local medical advisor/physician should determine if and how Scoliometer readings will be followed – up. For more information about the Scoliometer, contact:
Scoliometer National Scoliosis Foundation, Inc.
Orthopedic Systems, Inc. or 5 Cabot Place
1897 National Avenue Stoughton, MA 02072
Hayward, CA 94545 (800) 673-6922
(415) 785 – 1020 www.scoliosis.org
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