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Information Form

Stretching & Exercise Program

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Question 1 of 12

First Name/Surname

Question 2 of 12

DOB (DD/MM/YYYY)

Question 3 of 12

Email Address

Question 4 of 12

How frequently would you like to do the stretches/exercises?

A

Everyday

B

Every second day

C

A few times a week

Question 5 of 12

Realistically, how much time will you have to complete the stretches/exercises? This will help tailor the program to suit your needs. 

A

Up to 15 minutes

B

15-30 minutes

C

30+ minutes

Question 6 of 12

Do you have any preexisting injuries or illnesses? This will help tailor your program to your needs and limitations.

Question 7 of 12

Are you currently taking any medications which may impact your ability to complete certain exercises?

Question 8 of 12

Do you have any equipment available to you? No equipment is necessary for your program, however if you do you have equipment this will help tailor the stretches and exercises.

(Select all that apply)
A

Resistance band

B

Foam Roller

C

Dumbbells (1-5kg)

D

Dumbbells (6-10kg)

E

Dumbbells (10kg+)

F

N/A

Question 9 of 12

If you have access to a gym, would you like gym-based strength exercises included in your program, if applicable?

A

Yes

B

No

C

N/A

Question 10 of 12

Tell me in as much detail as you like - What pain and restrictions you have been experiencing that you would like addressed in your program?

EXAMPLE 1: I have lower back pain and stiffness that I experience from sitting at a desk and I want some stretches and mobility exercises that I can do to help relieve this

EXAMPLE 2: I often experience neck and shoulder tightness with some headaches and I want some stretches

EXAMPLE 3: I have poor posture and I would like exercises to help me move better and improve my posture

Question 11 of 12

What kind of exercises you would like i.e. stretches, mobility exercises

Question 12 of 12

Any other details/preferences you would like to add?

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