Dancer Medical History Form
(Pre-season Screen)
Name
*
First Name
Last Name
Date of Birth
*
Today's Date
*
Gender
Please Select
Female
Male
Other/Not Specified
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?
Please Select
Dancer
Parent
Health History
Health Conditions (Please check any that you have or have had in the past)
Stress Fracture
Asthma
Anemia
Scoliosis
Dizziness/Fainting
Shortness of Breath
Blood Pressure abnormalities
Diabetes
Seizures
Heart Conditions
No Health Issues
Please list any other health conditions and/or provide information on current conditions.
Have you had any surgeries?
Yes
No
Please provide date (year and month) of surgeries and brief description.
Do you take any medications (prescription or over-the-counter)?
Yes, I currently take some medications regularly.
No, I am not currently taking any medications.
Do you take any vitamins or dietary supplements?
Yes, I currently take some vitamins or dietary supplements regularly.
No, I am not currently taking any vitamins or dietary supplements regularly.
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?
Yes
No
Describe your menstrual cycle (periods)
I have not yet started my period
Irregular
Regular, < 24 days apart
Regular, 24-32 days apart
Regular, >32 days apart
Menopause
N/A
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?
Yes
No
Do you do pointe work?
Yes
No
Age began pointe?
Please select the category that best describes your performance activity
Company or studio dance performance (ballet, contemporary, etc)
Competition dancer
No performances
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?
Yes
No
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?
Yes
No
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?
Yes
No
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?
Please Select
Class
Theater
Rehearsal
Other- dance related
Other - not dance related
Multiple answers apply
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.
Submit
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