Sciatica-Friendly Exercise Intake Form
Please provide the following information to help us tailor safe and effective exercise guidance for your needs.
Full Name
*
First Name
Last Name
Age
*
Email Address
*
example@example.com
How would you describe your current activity level?
*
Sedentary
Lightly active
Moderately active
Very active
Other
How often do you currently exercise?
*
Please Select
Never
1-2 times per week
3-4 times per week
5 or more times per week
How long have you experienced sciatica symptoms?
*
Less than 1 month
1-3 months
3-12 months
Over 1 year
What is your current level of discomfort?
*
No discomfort
1
2
3
4
5
6
7
8
9
Severe discomfort
10
1 is No discomfort, 10 is Severe discomfort
Do you have any exercise restrictions or previous injuries?
*
Lower back pain (non-specific)
Knee discomfort
Hip discomfort
None
Other
What are your primary exercise goals?
*
Pain management
Increase flexibility
Improve strength
Increase mobility
General wellness
Other
Preferred types of exercise (select all that apply)
*
Stretching
Yoga or Pilates
Walking
Strength training (bodyweight)
Other
Additional comments or considerations
Submit
Should be Empty: