Dancer Medical History

Dancer Medical History Form

(Pre-season Screen)
Name

First NameLast Name
Date of Birth
Today's Date
Gender
Dancer Email
Dancer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent Email
Parent Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Which email address is preferred for receiving screening information?
Health History
Health Conditions (Please check any that you have or have had in the past)
Please list any other health conditions and/or provide information on current conditions.
Have you had any surgeries?
Please provide date (year and month) of surgeries and brief description.
Do you take any medications (prescription or over-the-counter)?
Do you take any vitamins or dietary supplements?
Please list names, dosages, and frequency of all medications and vitamins/supplements.
Do you have a dietary restrictions or food intolerances (vegan, vegetarian, gluten-free)? If "yes" please describe.
Do you have allergies other than seasonal? If yes, please describe.
Do you have difficulty maintaining your current body weight?
Describe your menstrual cycle (periods)
Dance/Performance History
What company/studio do you currently dance with?
Main type of dance training
Additional forms of dance training
Number of hours of class/week
Number of hours of rehearsal/week
Age began dancing
Has your training been continuous?
Do you do pointe work?
Age began pointe?
Please select the category that best describes your performance activity
Please list performances and approximate number of shows last dance season. Include competitions if applicable. (Example: Nutcracker 10, Giselle 5, Showcase 3, YAGP)
Please list number of competitions attended last season and average number of dances per competition (Example: 15 competitions: 3 solos, 5 group dances)
Exercise History
Do you participate in cross training/exercise outside of dance studio classes?
Please describe the type of cross-training and when it is done (during the dance season, off-season, pre-season, etc.)
Do you do cardiovascular training?
Current # of hours/week of cardio training
Injury History
Have you had any musculoskeletal injuries in the past 12 months that caused you to miss dance activities such as class, rehearsal, or performance?
Were you seen by a healthcare practitioner? If yes, what type of healthcare provider (PT, orthopedist, chiropractor, etc)?
What was the diagnosis or area(s) that were injured?
Where did the injury occur?
Have you had PT in the last 12 months? If yes, please list injured areas.
Please list any continuing concerns or problems due to injury or other pertinent history.
Should be Empty:

Dancer Medical History Form

Health History

Dance/Performance History

Exercise History

Injury History