Scolio Pilates Intake FormClient Name: * Date Instructor Name: Scoliometer Reading:C/S (if possible) C7 T/5 T12 L5 Apex at Cervical? YesNo Which side is high in posterior view? RightLeft Apex at Thoracic? YesNo Which side is high in posterior view? RightLeft Apex at Lumbar? YesNo Which side is high in posterior view? RightLeft Pelvic compensation? YesNo Which side is high in posterior view? RightLeft Thoracic Expansion Indicate centimeters of expansion on inhale from a relaxed position (not from complete exhale). Client's Height Exercise AssessmentsI. Proprioception - Single Leg StanceSeconds with eyes open: (up to 30 seconds) Seconds with eyes closed (up to 30 seconds) Client unable to do: eyes openeyes closed II. Ability to elongate the spineOf the following elongation exercises, which is the most appropriate starting elongation exercise for this client? Standing traction; reach for the ceilingElongation on the reformer; prone on long boxBelt at the ASIS elongationHanging elongation from the Cadillac or bar Why? Please indicate why the elongation exercise you chose was most appropriate. III. Need a Title?Using the Fletcher system of breathing: Sniffing or blowing for each count of inhale or exhale, what count is your client able to achieve with even breath intake on each sniff and even outtake on each blow? Please indicate number between 1 and 10 IV. Gluteal Strength / EnduranceSide-lying Leg Series: Bottom leg bent; top leg straight (Right Leg Working)Up/Down - 10x's. Client Clompleted: enter number of reps 30 sec hold; parallel to mat. Client Completed: enter number of seconds 10 Circles each direction. Client Completed: enter number of reps Clams. 10x's. Client Completed: enter number of reps Lower leg lifting. 10x's. Client Completed: enter number of reps Double-leg lift. 10x's. Client Completed: enter number of reps Side-lying Leg Series: Bottom leg bent; top leg straight (Left Leg Working)Up/Down. 10x's. Client Completed: enter number of reps 30 Sec Hold; parallel to mat. Client Completed: enter number of seconds 10 Circles each direction. Client Completed: enter number of reps Clams. 10x's. Client Completed: enter number of reps Lower leg lifting. 10x's. Client Completed: enter number of reps Double-leg lift. 10x's. Client Completed: enter number of reps V. Bridging (Feet at sides of mat in external rotation)Gluteal engagement on bridging: YesNo Hamstring cramping on bridging: YesNo Back discomfort on bridging: YesNo VI. Spine extension. Single leg lift. (Prone, resting the forehead on the fingertips, legs in external rotation)Client able to achieve t/s extension? YesNo Client able to lift and hold for 30 seconds: enter number of seconds achieved Single leg lift. Client able to achieve gluteal activation? YesNo Single leg lift. Able to hold 30 Second: enter number of seconds achieved VII. Single leg lift in Supine. (Supine with non-working leg bent with sole of foot on the mat, knee to the ceiling. Neurtral spine position. Hands placed behind l/s.)A. R s/l lift. Lift and hold for 10 Seconds. enter number of seconds achieved Neutral? YesNo B. L s/l lift. Lift and hold for 10 seconds. enter number of seconds achieved Neutral? YesNo C. Repeat (A) with elbows lifted. enter number of seconds achieved Neutral YesNo D. Repeat (B) with elbows lifted. enter number of seconds achieved Neutral YesNo E. Repeat (C) with head lifted. enter number of seconds achieved Neutral? YesNo F. Repeat (D) with head lifted. enter number of seconds achieved Neutral? YesNo VerificationPlease enter any two digitsExample: 12This box is for spam protection - please leave it blank Kristy CooperScolio Pilates Intake10.28.2014
