Fibromyalgia Exercise Program Intake Form
Complete this intake form so the exercise program can be tailored to your symptoms, goals, and current activity level.
Participant Information
Full Name
*
First Name
Middle Name
Last Name
Preferred Name
Age
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Email
Phone
Either
Fibromyalgia Background and Current Status
Fibromyalgia diagnosis status
*
Diagnosed
Suspected
Not diagnosed
Prefer not to say
Time since diagnosis
*
Please Select
Less than 6 months
6–12 months
1–2 years
3–5 years
More than 5 years
Unsure
Current symptom severity
*
1
2
3
4
5
Main symptom areas affected
*
Widespread muscle pain
Tender points
Neck and shoulders
Back
Hips
Arms
Legs
Headaches
Brain fog
Other
Common flare-up triggers
*
Stress
Poor sleep
Overexertion
Weather changes
Prolonged sitting or standing
Physical activity
Caffeine
Certain foods
Menstrual cycle
Other
Sleep quality
*
1
2
3
4
5
Fatigue level
*
1
2
3
4
5
Current activity limitations
Exercise History and Preferences
Current activity level
*
Sedentary
Lightly active
Moderately active
Very active
Not sure
Previous exercise experience
*
None
Beginner
Some regular experience
Experienced
Not sure
Activities you enjoy
Walking
Swimming
Cycling
Yoga
Pilates
Strength training
Stretching
Dancing
Low-impact aerobics
Other
Activities you want to avoid
High-impact exercise
Running
Jumping
Heavy lifting
Group classes
Floor exercises
Overhead movements
Other
Preferred exercise setting
*
Home
Gym
In-person
Virtual
Preferred intensity
*
Very gentle
Light
Moderate
Mixed/varies by day
Availability for sessions
Morning
Midday
Afternoon
Evening
Weekdays
Weekends
Flexible
Health Considerations and Safety Screening
Mobility limitations that may affect exercise
None
Walking difficulty
Stair climbing difficulty
Getting up from floor/chair difficulty
Reaching or lifting difficulty
Other
Balance concerns during movement
None
Occasional unsteadiness
Frequent unsteadiness
Dizziness with position changes
Fear of falling
Other
Areas of pain or discomfort during activity
Neck
Shoulders
Back
Hips
Knees
Feet/ankles
Hands/wrists
Widespread body pain
Other
Recent injuries or physical concerns to consider
Medications or substances that may affect exercise tolerance
None
Pain medication
Muscle relaxant
Sleep medication
Blood pressure medication
Antihistamine
Other
Assistive devices used when walking or exercising
None
Cane
Walker
Brace or support
Orthotic inserts
Hearing or vision aid
Other
Have you been advised to limit physical activity?
*
No
Yes
Not sure
Program Goals and Consent
Acknowledge and Consent
*
I understand that I am participating in the fibromyalgia exercise program and will report any worsening symptoms or discomfort
I agree to follow the program guidelines and communicate changes in my condition
Other
Exercise Goals
*
Preferred Pace or Priority
Gentle and gradual progression
Balanced improvement in strength and endurance
Focus on pain management and symptom stability
Flexibility and mobility first
Other
Submit Intake
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