Pre Consultation Questionnaire Pre Consultation Health and Training Questionaire Pre ConsultationHealth & TrainingQuestionnaire A confidential starting point for understanding your goals, experience, health considerations, and coaching needs. Privacy and health informationSteadfast Strength and Mobility, LLC uses the exercise relevant health information you provide to assess readiness, plan your consultation and consider appropriate coaching or medical clearance. Responses are stored in our WordPress form system. Please share only relevant details and provide emergency contact information with that person’s knowledge.Read our Privacy Policy for information about service providers, retention and your rights. To ask about your information or withdraw consent, email justin.stead@steadfaststrengthandmobility.com. Withdrawal does not undo earlier lawful processing; without necessary information we may be unable to assess safe participation. This form does not subscribe you to marketing.First NameLast NameEmailPHONE NUMBER HOME ADDRESSAddress Line 1Address Line 2CityStateZip CodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)RomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweDATE OF BIRTHPRO NOUNS- Select -HE/HIMSHE/HERTHEY/THEMPREFER NOT SAY Goals & Experience Tell me what you want to accomplish, what you have tried before, and what has made progress difficult. What would you like to accomplish through coaching? (check all that Apply) Build Strength Improve Mobility and Flexibility Lose Body Weight Build Muscle Improve Balance and Stability Reduce discomfort during daily Movement Improve energy and conditioning Return to exercise Safely Improve Athletic Performance OtherDescribe your primary goal in your own wordsHow would you describe your current exercise experience? New to Structured exercise Returning after an extended break Beginner Intermediate AdvancedWhat exercise or physical activities are you currently doing?What types of training, sports, or physical activities have you done in the past? What has made it difficut to reach your goals? (Check all that apply) Limited time Inconsistent schedule Pain, injury, or surgery Lack of accountability Unsure what to do Loss of Motivation Work or Family Previous Programs were not sustainable OtherIs there anything else you would like me to understand about your goals, experience, or previos challenges? Health & Movement Screening Please answer honestly. Include only information relevant to safe exercise and coaching. Are you currently experiencing pain, discomfort, numbness, weakness, or restricted movement? Yes NoIf yes, describe the affect area, symptoms, severity, and movements that make it better or worse Have you had any injuries, surgeries, hospitalizations, or significant medical procedures that may affect exercise? Yes NoIf Yes, please describe what happened, the approximate date, you current recovery status, and any remaining limitationsHas a physcian or healthcare professional given you any restrictions, precautions, or recommendations related to exercise? Yes NoIf yes, describe the exercise restrictions, precautions, or recommendations.Are you currently taking any medications that may affect exercise, Heart rate, blood pressure, balance, hydration, or recovery? Yes NoIf yes, or unsure, list the medication and explain anything relevant to exercise.Have you been diagnosed with any medical condition that may affect your ability to exercise safely? Yes No UnsureIf yes or unsure, describe the condition and explain how it may affect exercise. Exercise Safety Screening Please answer each question honestly. A “Yes” response may require additional discussion or medical clearance before exercise begins. Has a healthcare professional ever told you that you have a heart condition or that you should participate in physical activity only as medically recommended? Yes No UnsureDo you feel pain, pressure, tightness, or discomfort in your chest during physical activity? Yes No UnsureIn the past month, have you experienced chest pain, pressure, tightness, or discomfort when you were NOT physically active? Yes No UnsureDo you experience dizziness, loss of balance, fainting, or loss of consciousness? Yes No unsureDo you have a bone, jont, muscle, or balance problem that could be worsend by physical activity? Yes No UnsureDo you know of any other reason why you should not participate in physical activity without first consulting a healthcare professional? Yes No UnsureIf you answered Yes or Unsure to any Exercise Safety Screening question, Please explain. Lifestyle & Availability Help me understand your schedule, daily demands, and the coaching format that will fit your life. Which coaching format are you most interested in? In person personal training Online coaching Hybrid Coaching Mobility focused coaching Not sure yetWhich days are you generally available for coaching or training? (Check all that apply) Monday Tuesday Wednesday Thursday Friday Saturday Schedule VariesWhat times are you generally available for coaching or training? (Check all that apply) Early Mornings before 8 a.m. Morning, 8:00 a.m. to 12:00 p.m. Afternoon, 12:00 p.m. to 4:00 p.m. Evenings, 4:00 p.m. to 8:00 p.m. Schedule VariesHow many days per week can you realistically commit to structured exercise? 1 day 2 days 3 days 4 days 5 or more days Not sure yetHow much time can you realistically dedicate to each exercise session? Less than 30 mins 30 to 45 mins 46 to 60 mins 61 to 90 mins more than 90 mins it variesWhere do you expect to complete most of your training? At Home independently Commercial gym Apartment or community gym Outdoors In Person with Steadfast at my home, outdoors, or another agreed location Combination of locations Not Sure yetWhat types of support would help you stay consistent? Selct all that apply. Scheduled personal training sessions A structured workout plan Regular accountability check-ins Nutrition and habit guidance Exercise demonstrations and feedback Progress tracking Not sure yetIs there anything about your schedule, work, family responsibilities, travel, or access to equipement that may affect your ability to train consistently? What exercise equipment do you currently have access to? How ready are you to begin making consistent changes to your training, recovery, and daily habits? Ready to begin NOW Ready within the next two weeks Interested, but still evaluating my options Gathering information for the future UnsureWhich statement best describes your current readiness to invest in professional coaching if we determine the Steadfast is a good fit? I am prepared to begin if the service and price fit my needs I may be ready, but I need to review the options and pricing first I need to discuss the decision with someone else I am gathering information and am not ready to invest yet Emergency Contact, Acknowledgment & Signature Please provide an emergency contact, review the statements below, and confirm that the information you submitted is accurate. First NameLast NameEmergency Contact Phone number Relationship to youExplicit consent to use health information I explicitly consent to Steadfast Strength and Mobility, LLC collecting and using the health information I choose to provide for exercise readiness assessment, consultation and coaching service planning, as explained in the Privacy Policy. I understand how to withdraw this consent.Please confirm each statement before submitting I confirm that information I provided is accurate and complete to the best of my knowledge. I understand that this questionaire is for exercise screening and consultation planning and is NOT medical advice, diagnosis, or treatment. I understand that submitting this form does NOT create a trainer client relationship or guarentee the exercise services will be appropriate for me. I agree to tell Steadfast Strength and Mobility about relevant changes to my health, symptoms, restrictions, or medications before participating in exercise. I understand that Steadfast may request medical clearance or decline or postpone exercise services when saftey concerns require it. I consent to Steadfast Strength and Mobility collecting and reviewing the exercise relevant information submitted through this form for consultation and service planning.Communication Consent I consent to be contacted by Steadfast Strength and Mobility about my consultation and requested services by email, phone, or text message. Type your full name as your electronic signatureSubmit Questionnaire
