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Form #4400
Certificate of Scoliosis Screening
Required for students entering 6
th
and 8
th
grade
Form must be completed in its entirety and returned within 90 days of school start
Student name: ________________________________________________________________________
First Middle Last
Date of Birth: _ _ /_ _ /_ _ _ _ Gender: Male___ Female___ Grade: _____
Student Address: __________________________________________________________________
Street City
_________________________________________________________________
Zip code County State
Name of School: _______________________________________________________________________
Parent/Guardian Contact information:
Name: _______________________________________________________________________________
Phone number: ________________________________________________________________________
Email: _____________________________________@_________________________________________
Scoliosis Screening (Adams Forward Bend Test) Results:
Negative screen: _______
Needs further evaluation: ______
Referred to provider: ______
Screener’s Comments:
Screening completed by:
Physician Practice: _____ County Health Department: _____
Licensed School Nurse: _____
Screener Information:
Name: ___________________________ Office Address: ______________________________________
Signature: ______________________________________________________ Date: _ _ / _ _ / _ _ _ _
Parent/Guardian – Complete This Portion Only if Student Will Not Be Screened
Opt-out
_____I do not want my student to be screened for scoliosis at this time.
_____The student listed above is currently under professional care for scoliosis.
Parent/Guardian’s Signature: ___________________________________________Date: _ _ / _ _ / _ _ _
Georgia Department of Public Health
Form #4400
Certificate of Scoliosis Screening
What is scoliosis?
Scoliosis is an abnormal curvature of the spine. If detected early in a child’s life, it may be possible to treat the condition
and prevent it from becoming more serious.
Who is required to file this Form #4400?
The parent or guardian of a student entering the 6
th
grade shall furnish to school authority a properly executed DPH
Form #4400, Certificate of Scoliosis screening, as early as the first day of 5
th
and no later than 90 days after the student
begins 6
th
grade. The parent or guardian of a student entering the 8
th
grade shall furnish to school authority a properly
executed Form #4400, Certificate of Scoliosis screening, as early as the first day of 7
th
and no later than 90 days after the
student begins 8
th
grade.
These time periods were chosen because these are the years when rapid growth occurs, and scoliosis is most likely to
become observable.
What is the purpose of Form #4400?
Form #4400 is intended to ensure every child in Georgia public schools is screened for spinal deformities. The earlier
these problems are detected the earlier parents/guardians can seek professional help for their student.
What screenings are required?
The “Adams Forward Bend Test” is required, and the results must be documented on the Form #4400 before it is filed
with the school. The Adams Forward Bend test is a simple painless observation of the child’s back as he or she stands
and bends over.
Who can conduct the screenings?
The test can be conducted by a physician with an active GA license or person working under the supervision of a
physician with an active GA license, the local health department, and licensed school nurses.
What should a parent do if the “Needs further evaluation” box is checked?
If the “Needs further evaluation” box is checked, then the parent/guardian should take the student to a medical
provider for a more detailed evaluation. Your physician or local health department may be able to help or recommend
someone who can help.
What if a Form #4400 was previously filed for the child at another school?
Form #4400 should become part of the student’s permanent record. If a student transfers schools, the school where the
form was filed is required to forward Form #4400 to the new school.
What happens if Form #4400 is not completed for students in 6
th
and 8
th
grades?
Students without Form #4400 on file will be screened by school staff during a mass scoliosis screening event during the
school year.
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Completed 15 November 2021

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