Professional Dancer Medical History Form
Name
*
First Name
Last Name
Email
Phone
Date of Birth
*
Today's Date
*
Gender Assigned at Birth
*
Female
Male
Not specified
Gender Identity
Female
Male
Transgender
Non-binary
Other
Health History
Health Conditions (Please check any that you have or have had in the past)
Stress Fracture
Asthma
Scoliosis
Dizziness/Fainting
Shortness of Breath
Blood Pressure abnormalities
Diabetes
Seizures
Heart Conditions
Chronic Pain
I do not have any significant 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.
Please indicate if you use any of the following:
Caffeine
Alcohol
Nicotine products
Recreational drugs
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?
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
At what age did you start having a menstrual cycle?
Dance/Performance History
What company do you currently dance with?
Main type of dance training
Additional forms of dance training
Please list performances and approximate number of shows last dance season. Include competitions if applicable. (Example: Nutcracker 10, Giselle 5, touring 20, etc)
Please list average number of hours spent in dance related activity per week.(Example: technique class 10, rehearsals 20, teaching 6 etc)
Exercise History
Do you participate in cross training/exercise outside of the dance studio?
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 and type 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.
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 or are relevant to your care.
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