Scolio Pilates Intake FormClient Name: *Date Instructor Name: Scoliometer Reading:C/S (if possible) C7 T/5 T12 L5 Apex at Cervical? YesNoWhich side is high in posterior view? RightLeftApex at Thoracic? YesNoWhich side is high in posterior view? RightLeftApex at Lumbar? YesNoWhich side is high in posterior view? RightLeftPelvic compensation? YesNoWhich side is high in posterior view? RightLeftThoracic 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 closedII. 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 barWhy? 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 10IV. Gluteal Strength / EnduranceSide-lying Leg Series: Bottom leg bent; top leg straight (Right Leg Working)Up/Down - 10x's. Client Clompleted: enter number of reps30 sec hold; parallel to mat. Client Completed: enter number of seconds10 Circles each direction. Client Completed: enter number of repsClams. 10x's. Client Completed: enter number of repsLower leg lifting. 10x's. Client Completed: enter number of repsDouble-leg lift. 10x's. Client Completed: enter number of repsSide-lying Leg Series: Bottom leg bent; top leg straight (Left Leg Working)Up/Down. 10x's. Client Completed: enter number of reps30 Sec Hold; parallel to mat. Client Completed: enter number of seconds10 Circles each direction. Client Completed: enter number of repsClams. 10x's. Client Completed: enter number of repsLower leg lifting. 10x's. Client Completed: enter number of repsDouble-leg lift. 10x's. Client Completed: enter number of repsV. Bridging (Feet at sides of mat in external rotation)Gluteal engagement on bridging: YesNoHamstring cramping on bridging: YesNoBack discomfort on bridging: YesNoVI. Spine extension. Single leg lift. (Prone, resting the forehead on the fingertips, legs in external rotation)Client able to achieve t/s extension? YesNoClient able to lift and hold for 30 seconds: enter number of seconds achievedSingle leg lift. Client able to achieve gluteal activation? YesNoSingle leg lift. Able to hold 30 Second: enter number of seconds achievedVII. 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 achievedNeutral? YesNoB. L s/l lift. Lift and hold for 10 seconds. enter number of seconds achievedNeutral? YesNoC. Repeat (A) with elbows lifted. enter number of seconds achievedNeutral YesNoD. Repeat (B) with elbows lifted. enter number of seconds achievedNeutral YesNoE. Repeat (C) with head lifted. enter number of seconds achievedNeutral? YesNoF. Repeat (D) with head lifted. enter number of seconds achievedNeutral? YesNo VerificationPlease enter any two digitsExample: 12This box is for spam protection - please leave it blank Kristy CooperScolio Pilates Intake10.28.2014
