MEDICAL HISTORY VAB acknowledges the sensitivity of personal information and takes care to ensure the confidentiality and security of personal information. The information disclosed on this form is strictly confidential and only shared with VAB staff as required. Should there be any questions regarding your medical history, we will be in touchPlease complete form in English.Student First Name *Student Preferred Name Student Last Name *Student Pronouns *Example: She/Her, He/Him, They/ThemPlease disclose all previous medical history and pre-existing medical conditions:Mental & Emotional Health: AnxietyDepressionInsomnia/Sleep ProblemsEating DisorderOtherOther - Please describe: *Muscle & Joint Health: ArthritisTendonitisMuscle WeaknessMuscle CrampsHeavy LimbsOtherOther - Please describe: *Head, Neck & Spine Health: Regular HeadachesMigrainesScoliosisOtherOther - Please describe: *Heart, Lunge & Chest Health: Shortness of breathHyper/Hypotension (high/low blood pressure)AsthmaOtherOther - Please describe: *Dental Health:Please list and describe any recent, significant dental issues you have been experiencing: Have you been advised of any upcoming necessary dental procedures? If yes, please describe: Please list and describe any surgeries, hospitalizations, or significant traumas: Please list any medications you are currently taking: Please list any allergies: Are you up to date with your vaccinations (excluding the COVID-19 vaccination)? YesNoUnsureIn the past 2 years, have you regularly visited any of the following healthcare practitioners? TherapistPsychiatristPsychologistCounsellorPhysiotherapistAcupuncturistKinesiologistChiropractorOccupational TherapistNaturopathOtherOther - Please describe: *Please describe anything, not already mentioned on this form, that might be relevant to Victoria Academy of Ballet and/or your training: The information included in this form is accurate, complete, and up to date: *I AgreeDate: *NameSubmit
