Dancer Medical History

Name*

First NameLast Name

Date of Birth*

Today's Date*

Gender Assigned at Birth*

femalemale

Gender Identity

What is the primary concern or goals that you would like to have addressed?

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 or injuries that have had an impact on your movement for longer than a few weeks?

YesNo

Please provide date (year and month) of surgeries or injuries 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.

Please indicate if you use the following.

Please describe dosage/quantity and frequency with which you use the above.

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?

YesNo

Describe your menstrual cycle (periods)

At what age did you start having a menstrual cycle?

On average, how many hours of sleep do you get per night?

Do you have difficulty sleeping?

NoYes

Please describe the difficulties you have with sleeping.

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?

YesNo

Do you do pointe work?

YesNo

Age began pointe?

Please select the category that best describes your performance activity

Company or studio dance performance (ballet, contemporary, etc)Competition dancerNo 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)

Do you participate in cross training/exercise outside of dance studio classes?

YesNo

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?

YesNo

Current # of hours/week of cardio training

Have you had any musculoskeletal injuries in the past 12 months that caused you to miss dance activities such as class, rehearsal, or performance?

YesNo

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.

Please list the name and phone numbers or practice of your primary care physician, orthopedist, and any other care providers that you are currently seeing.

Dancer Medical History Form

Health History

Dance/Performance History

Exercise History

Injury History