ENQUIRY FORM
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
Where are you located (City, Country)?
What is your Job/Occupation
What best describes your current situation?
I have been formally diagnosed with axial spondyloarthritis (axSpA)
I have another form of inflammatory arthritis (e.g., PsA, RA, etc.)
I have not been diagnosed, but I suspect I may have axSpA or inflammatory arthritis
I’m supporting someone who has axSpA/inflammatory arthritis
Other
If diagnosed, what type of arthritis were you diagnosed with?
axSpA
nr-axSpA
AS
PsA
RA
IBD-associated arthritis
Other
When were you diagnosed (month/year)?
-
Month
-
Day
Year
Date
Are you currently under medical care for this condition?
Yes
No
Infrequently
What treatments are you currently doing or have recently done for your condition?
Medication (e.g., NSAIDs, biologics)
Physical therapy
Exercise/movement routines
Strength training
Stretching/flexibility programs
Yoga
Diet or nutrition changes
Supplements
Manual therapy (e.g., massage, chiropractic)
Acupuncture
Mindfulness
Stress-reduction practices
I'm not currently doing any treatment
Other
What are the main physical symptoms you're currently dealing with?
Stiffness
Pain
Fatigue
Reduced mobility
Muscle weakness
Joint swelling
Gut issues (e.g. bloating, constipation, IBD)
Sleep disturbance
Anxiety/depression
Other
Where in your body do you experience the most symptoms?
Neck
Upper back
Lower back
Sacroiliac joints (hips/pelvis)
Hips
Knees
Shoulders
Wrists
Ankles
Feet
Chest/ribs
Gut
Other
How would you describe your current mobility level?
Fully mobile and independent
Mostly mobile but with limitations
Mobile with assistive devices
Limited mobility and require assistance
What physical activities do you currently do (if any)?
Walking
Yoga
Stretching
Strength training
Swimming
Cycling
None currently
Other
What are your top 3 health goals?
Which of these areas would you most like to improve?
Strength
Flexibility
Pain management
Stress reduction
Nutrition
Gut health
Daily habits/routines
Sleep
Mind-body connection
Other
On a scale from 1 to 5, how ready do you feel to make changes to your health and routine right now?
Not ready
1
2
3
4
Ready
5
1 is Not ready, 5 is Ready
Is there anything else you’d like me to know about your condition, your goals, or how I can support you?
What time zone are you in?
How did you hear about me?
Instagram
Tik Tok
YouTube
Facebook
Podcast
Friend or family referral
Support group or forum
Google search
Newsletter or email
In-person event or talk
My healthcare provider
Other
Intake Agreement & Acknowledgement
*
By submitting this form, I understand this is an inquiry and not a guarantee of coaching availability. I acknowledge this program is not a substitute for medical care.
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