Scolio-Pilates IntakePlease complete this form before attending your first Scolio-Pilates sessions. Name * First Name Last Name Email * Phone * Country (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of birth * Emergency contact Name and phone number: * Have you been diagnosed with any of the following? * Scoliosis Kyphosis Kypho-scolosis Hyper-Lordosis Other When was your condition first diagnosed? * Our system asks for the exact day but if you don't know the exact day, just something close to that time is fine. MM DD YYYY who diagnosed this condition? * Medical doctor Physical therapist Chiropractor Self-diagnosed Other Is your diagnosis a result of some other condition? (e.g. neurological, muscular, bone) * Are you seen by a medical doctor (not a chiropractor or physical therapist) regarding this condition? * Yes No Other If you are seeing a medical doctor, please include name and phone number Do you have X-rays or MRI? * Yes (You will be asked to email these prior to our first session) No (Please obtain x-rays or MRIs before our first session) Have you been diagnosed with other spine concerns? * Herniated or bulging disc Osteoporosis or osteopoenia Facet Joint Syndrome Degenerative disc disease Stenosis Nerve impingement Other If you know the degree (Cobb angle) of your curves, please list them below. For example, Thoracic: 35; Lumbar 47. If you don't know the degree, then just write, "I don't know." * Has the degree changed since you were first diagnosed? * Yes No Not sure Other Have you ever worn a scoliosis brace? * Yes No If yes, how long? what age were you when you wore the brace? What kind of brace? Have you ever had difficulty breathing? If yes, do you know why? Have you had spinal fusion for your scoliosis? * Yes No If yes, when was it performed? When you performed the exercises or physical therapy, what results were you hoping for? * Did you achieve the results you were hoping for? * Yes No For both yes and no answers, what is your opinion on why the result was or was not achieved? * Please share the level of comfort or discomfort that you feel as a result of your scoliosis. * 1- I have no pain 10- I am in so much pain, I need to go to the hospital 1 2 3 4 5 6 7 8 9 10 If you have pain symptoms, when are the symptoms their worst? (Choose all that apply) * Morning Afternoon Evening Sleeping Other If you have pain, what makes the symptoms better? * If you take medication, please list here: * What is your physical activity level? How many times a week? (from walks to working out) * What are you hoping to achieve from a Scolio-Pilates program? * Anything else in your scoliosis history that you would like to share? * Please confirm that you have read the following release: I have enrolled in a strenuous physical activity program, including exercise on, with, and without the Pilates equipment and related pillows and devices offered by Julie Selwood. I hereby affirm that I am in good physical condition and do not suffer from any disability that would prevent or limit my participation in this exercise program. Considering my participation in this exercise program, I, for myself, my heirs, and assigns, hereby release and indemnify and hold harmless Julie Selwood from any claims, demands, and causes of action arising from my participation in the exercise program. I fully understand that I may injure myself as a result of my participation in this Pilates exercise program. I hereby release Julie Selwood from any liability now or in the future, including, but not limited to, muscle soreness and fatigue, heart attacks, muscle strains, pulls or tears, broken bones, shin splints, heat prostration, knee/lower back/foot injuries and any other illness including mental, soreness or injury, however, caused, occurring during or after my participation in the exercise program. * * I have read and understand the liability release Typing my name below will constitute a signature that I understand and have read the above liability release. * Thank you!
