Pre Consultation Health and Training Questionaire Privacy and health information Steadfast 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.
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Country
Select Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Saint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czech Republic Democratic Republic of the Congo (Kinshasa) Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea North Macedonia Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Republic of the Congo (Brazzaville) Romania Russia Rwanda Réunion Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin (Dutch part) Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia/Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkmenistan Turks and Caicos Islands Tuvalu Türkiye Uganda Ukraine United Arab Emirates United Kingdom (UK) United States (US) United States (US) Minor Outlying Islands United States (US) Virgin Islands Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
PRO NOUNS
- Select - HE/HIM SHE/HER THEY/THEM PREFER 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)
Describe your primary goal in your own words
How would you describe your current exercise experience?
What 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)
Is 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?
If 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?
If Yes, please describe what happened, the approximate date, you current recovery status, and any remaining limitations
Has a physcian or healthcare professional given you any restrictions, precautions, or recommendations related to exercise?
If 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?
If 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?
If 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?
Do you feel pain, pressure, tightness, or discomfort in your chest during physical activity?
In the past month, have you experienced chest pain, pressure, tightness, or discomfort when you were NOT physically active?
Do you experience dizziness, loss of balance, fainting, or loss of consciousness?
Do you have a bone, jont, muscle, or balance problem that could be worsend by physical activity?
Do you know of any other reason why you should not participate in physical activity without first consulting a healthcare professional?
If 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?
Which days are you generally available for coaching or training? (Check all that apply)
What times are you generally available for coaching or training? (Check all that apply)
How many days per week can you realistically commit to structured exercise?
How much time can you realistically dedicate to each exercise session?
Where do you expect to complete most of your training?
What types of support would help you stay consistent? Selct all that apply.
Is 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?
Which statement best describes your current readiness to invest in professional coaching if we determine the Steadfast is a good fit?
Emergency Contact, Acknowledgment & Signature
Please provide an emergency contact, review the statements below, and confirm that the information you submitted is accurate.
Explicit consent to use health information
Please confirm each statement before submitting
Submit Questionnaire
