Home
News / Events
Prix de Lausanne’s medical questionnaire

Prix de Lausanne’s medical questionnaire

Prix de Lausanne’s medical process consists of an online medical form asking thorough questions regarding the dancer’s overall health. Please plan ahead and make an appointment with your doctor during the month of September as you will need to complete the online medical form along with your doctor.

Growth diagram

To complete your registration, please download the document below.

Only the following Prix de Lausanne’s diagram will be accepted, not a version of your physician.

Please upload the completed document in section 2 of the online questionnaire

Download the growth diagram

Medical questionnaire

Please answer every question in the presence of your medical practitioner.

Last name

First name

Birth date

Email address

Please note that all correctly completed forms will be confirmed by an automatic e-mail.
If this is not the case, we ask you to check that all the fields on the form have been filled in.

1. Dance participation

Age when the candidate started dancing?

Number of hours of dance per week (average) for the past year?

Number of hours of dance per week (average) for the current year?

2. Physical development

Current body weight (kilograms)

Height (centimetres)

Growth diagram filled in

Please indicate on the attached diagram the known data regarding the weight and height of the candidate during his/her growth

Resting pulse (Bpm)

Blood pressure (mm of Hg)

3. Family history

Father's height (cm)

Mother's height (cm)

Are you aware of the following events within your family (male relative<55 years, female <65 years) ? -- Cardiac or vascular disease ?

Sudden cardiac death (including sudden infant death)

If yes, please specify

4. Personal history

a. Surgical

Have you ever had any surgery ?

Please specify where and date:

b. Medical

Have you ever had any of the following?

Cardiac or vascular disease

Cardiac murmur or arrhythmias

High blood pressure

Diabetes

High cholesterol

Have you ever experienced the following symptoms during physical exercise ? -- Syncope, loss of consciousness

Chest pain

Palpitations, arrhythmias

Dizziness, abnormal shortness of breath

Epilepsy, seizure

Asthma

Recurrent ENT infection (otitis, sinusitis)

If yes, please specify

c. Allergies

Do you have any of the following ?

Respiratory allergy (asthma)

Cutaneous allergy

Food allergy

Drugs allergy

If yes, please specify

d. Injuries

Have you ever had: (please specify where and the date)

One joint dislocation or subluxation

One or several fractures

One or several joint sprains

One or several muscle lesions

One or several tendon ruptures

One or several tendinopathies

Back injuries

Growth-related injuries (e.g. knee, heel)

e. Medications

Have you taken any regular medication for the past 2 years ?

Please specify

Do you take any supplements or vitamins?

Please specify

f. Vaccinations

Have you been vaccinated?

Please join a copy of your vaccination status

5. Bone Health

a. Menstruration

How old were when you had your first period?

11 years or younger
12-14 years
15 years or older
I do not remember
I have never menstruated (If you choose this answer, there are no further questions to answer)

Do you have normal menstruation?

Yes
No
I do not know

If yes, when was your last period?

0-4 weeks ago
1-2 months ago
3-4 months ago
5 months ago or more

If yes, are your periods regular? (Every 28th to 34th day)

Yes, most of the time
No, mostly not

Do you use oral contraceptives?

If yes, why do you use oral contraceptives?

Contraception
Reduction of menstruation pain
Reduction of bleeding
To regulate the menstrual cycle in relation to performances
Otherwise menstruation stops

b. Bone injuries

Have you ever suffered from a stress fracture?

If yes, please specify where and the dates

c. Nutritional behaviour

Habitual diet

Varied
Vegetarian
Vegan
No dairy
No/limited carbohydrate
No/limited fat
Other

6. Eating Attitude Test

I like eating with other people

None of the time
A little of the time
Some of the time
Most of the time
All the time

I prepare food for others but do not eat what I cook

None of the time
A little of the time
Some of the time
Most of the time
All the time

I become anxious prior to eating

None of the time
A little of the time
Some of the time
Most of the time
All the time

I am terrified about being overweight

None of the time
A little of the time
Some of the time
Most of the time
All the time

I avoid eating when I am hungry

None of the time
A little of the time
Some of the time
Most of the time
All the time

I find myself preoccupied with food

None of the time
A little of the time
Some of the time
Most of the time
All the time

I have gone on eating binges where I felt that I may not be able to stop

None of the time
A little of the time
Some of the time
Most of the time
All the time

I cut my food into small pieces

None of the time
A little of the time
Some of the time
Most of the time
All the time

I am aware of the calorie content of foods that I eat

None of the time
A little of the time
Some of the time
Most of the time
All the time

I particularly avoid foods with a high carbohydrate content (e.g. bread, potatoes, rice, etc.)

None of the time
A little of the time
Some of the time
Most of the time
All the time

I feel bloated after meals

None of the time
A little of the time
Some of the time
Most of the time
All the time

I take longer than others to eat my meals

None of the time
A little of the time
Some of the time
Most of the time
All the time

I feel that others would prefer if I ate more

None of the time
A little of the time
Some of the time
Most of the time
All the time

I vomit after I have eaten

None of the time
A little of the time
Some of the time
Most of the time
All the time

I feel extremely guilty after eating

None of the time
A little of the time
Some of the time
Most of the time
All the time

I am preoccupied with a desire to be thinner

None of the time
A little of the time
Some of the time
Most of the time
All the time

I exercise strenuously to burn off calories

None of the time
A little of the time
Some of the time
Most of the time
All the time

I weigh myself several times a day

None of the time
A little of the time
Some of the time
Most of the time
All the time

I like my clothes to fit tightly

None of the time
A little of the time
Some of the time
Most of the time
All the time

I enjoy eating meat

None of the time
A little of the time
Some of the time
Most of the time
All the time

I wake up early in the morning

None of the time
A little of the time
Some of the time
Most of the time
All the time

I eat the same foods day after day

None of the time
A little of the time
Some of the time
Most of the time
All the time

I think about burning calories when exercising

None of the time
A little of the time
Some of the time
Most of the time
All the time

I have regular menstrual periods

None of the time
A little of the time
Some of the time
Most of the time
All the time

Other people think that I am too thin

None of the time
A little of the time
Some of the time
Most of the time
All the time

I am preoccupied with the thought of having fat on my body

None of the time
A little of the time
Some of the time
Most of the time
All the time

I enjoy eating at restaurants

None of the time
A little of the time
Some of the time
Most of the time
All the time

I take laxatives

None of the time
A little of the time
Some of the time
Most of the time
All the time

I avoid foods with sugar in them

None of the time
A little of the time
Some of the time
Most of the time
All the time

I eat diet foods

None of the time
A little of the time
Some of the time
Most of the time
All the time

I feel that food controls my life

None of the time
A little of the time
Some of the time
Most of the time
All the time

I display self-control around food

None of the time
A little of the time
Some of the time
Most of the time
All the time

I feel that others pressure me to eat

None of the time
A little of the time
Some of the time
Most of the time
All the time

I give too much time and thought to food

None of the time
A little of the time
Some of the time
Most of the time
All the time

I suffer from constipation

None of the time
A little of the time
Some of the time
Most of the time
All the time

I engage in dieting behaviour

None of the time
A little of the time
Some of the time
Most of the time
All the time

I like my stomach to be empty

None of the time
A little of the time
Some of the time
Most of the time
All the time

I enjoy trying new rich foods

None of the time
A little of the time
Some of the time
Most of the time
All the time

7. Mental health status

These questions relate to the past 30 days

It was difficult to be around other dancers

None of the time
A little of the time
Some of the time
Most of the time
All the time

I found it difficult to do what I needed to do

None of the time
A little of the time
Some of the time
Most of the time
All the time

I was less motivated

None of the time
A little of the time
Some of the time
Most of the time
All the time

I was irritable, angry, or aggressive

None of the time
A little of the time
Some of the time
Most of the time
All the time

I found training more stressful

None of the time
A little of the time
Some of the time
Most of the time
All the time

I could not stop worrying about injury or my performance

None of the time
A little of the time
Some of the time
Most of the time
All the time

I found it hard to cope with selection pressures

None of the time
A little of the time
Some of the time
Most of the time
All the time

I worried about life after my career

None of the time
A little of the time
Some of the time
Most of the time
All the time

I needed alcohol or other substances to relax

None of the time
A little of the time
Some of the time
Most of the time
All the time

I took unusual risks off-stage

None of the time
A little of the time
Some of the time
Most of the time
All the time

8. Current state of Health

Are you currently experiencing a health issue

If YES, please fill in the questions below.

To what extent are you experiencing symptoms/health complaints?

to a mild extent
to a moderate extent
to a severe extent

Are you having any difficulties participating in training and performing due to injury, illness, or other health problems?

full participation, with no health problems
full participation, but with health problems
reduced participation due a health problem
could not participate due to a health problem

Are you having to modify your training due to injury, illness, or other health problems?

to a minor extent
to a moderate extent
to a major extent

Please select where is your worst muscular and/or skeletal complaint you are experiencing:

no pain / complaint or injury (--> please go to question 5)
head
neck / cervical spine
chest / ribs
thoracic spine / upper back
abdomen
lumbar spine / lower back
pelvis / buttock
shoulder (including clavicle)
upper arm
elbow
forearm
wrist
hand
fingers / thumb
hip / groin
thigh
knee
lower leg / Achilles tendon
ankle
foot / toes

Other, please specify:

2a. Is this complaint / injury caused by dancing?

no
yes
don't know

2b. Is this complaint / injury new, recurrent, or chronic?

new (you never had this before)
recurrent after full recovery
worsening /chronic

3. Please select where your second worst muscular and/or skeletal complaint or injury you are experiencing is.

no pain / complaint or injury (--> please go to question 5)
head
neck / cervical spine
chest / ribs
thoracic spine / upper back
abdomen
lumbar spine / lower back
pelvis / buttock
shoulder (including clavicle)
upper arm
elbow
forearm
wrist
hand
fingers / thumb
hip / groin
thigh
knee
lower leg / Achilles tendon
ankle
foot / toes

Other, please specify:

3a. Is this complaint / injury caused by dancing?

no
yes
don't know

3b. Is this complaint / injury new, recurrent, or chronic?

new (you never had this before)
recurrent after full recovery
worsening /chronic

4. Please select where your third worst muscular and/or skeletal complaint or injury you are experiencing is.

no pain / complaint or injury (--> please go to question 5)
head
neck / cervical spine
chest / ribs
thoracic spine / upper back
abdomen
lumbar spine / lower back
pelvis / buttock
shoulder (including clavicle)
upper arm
elbow
forearm
wrist
hand
fingers / thumb
hip / groin
thigh
knee
lower leg / Achilles tendon
ankle
foot / toes

Other, please specify:

4a. Is this complaint / injury caused by dancing?

no
yes
don't know

4b. Is this complaint / injury new, recurrent, or chronic?

new (you never had this before)
recurrent after full recovery
worsening /chronic

5. Please select all other physical complaints (e.g., headache, menstrual pain) or illnesses (e.g., influenza, diarrhea) you are currently experiencing.

no illnesses or physical complaints
allergy, e.g., hay fever
asthma
flu, influenza, sinusitis, cold, cough
diarrhea, nausea, vomiting
headache, migraine
menstrual pain / cramps
heart palpations
fatigue, lack of energy

Others, please specify:

9. Conclusion

The dancer’s state of health including nutritional and mental state is:

To be filled by the medical practitioner

Satisfactory
Good
Excellent

Do you consider the dancer to be in overall good health and capacity of participating in a dance competition?

Date

Name of Physician

Email of Physician

Information compliance

The undersigned, declare that the information given in this application is correct and is given in good faith.

Data processing by MotionLab SA

By completing this form, applicants confirm that they agree to their personal data being processed by MotionLab SA.

The personal data collected on this form will be sent to MotionLab SA, the medical partner of the Prix de Lausanne 2024. It will be used by MotionLab SA to assess the state of health of candidates and to provide medical support to selected candidates during the event. This data will be processed in accordance with MotionLab SA's data protection declaration. This personal data may be passed on, in anonymised form, to the Fondation en faveur de l'Art Chorégraphique, organiser of the Prix de Lausanne, for statistical and research purposes.

formtype

Data privacy

I hereby confirm that the information I have provided is correct and that Swiss Medical Network can provide me with relevant information in the context of my request and thus accept the privacy policy.

Hospitals

Centres

For patients

About us

Hospitals

Centres

For patients

About us

How can we help you?

Top searches

Prix de Lausanne’s medical questionnaire

Growth diagram

Medical questionnaire