Dancer Medical History

  • Dancer Medical History Form

  • Gender Assigned at Birth*

  • Health History

  • Health Conditions (Please check any that you have or have had in the past)
  • Have you had any surgeries or injuries that have had an impact on your movement for longer than a few weeks?
  • Do you take any medications (prescription or over-the-counter)?
  • Do you take any vitamins or dietary supplements?
  • Please indicate if you use the following.
  • Do you have difficulty maintaining your current body weight?
  • Describe your menstrual cycle (periods)
  • Do you have difficulty sleeping?

  • Dance/Performance History

  • Has your training been continuous?
  • Do you do pointe work?
  • Please select the category that best describes your performance activity

  • Exercise History

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

  • Please think back over the last four weeks and respond to each item considering how often it applied to you. Please respond where:

    1) None of the time
    2) A little of the time
    3) Some of the time
    4) Most of the time
    5) All of the time

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  • Should be Empty: