ENQUIRY FORM

ENQUIRY FORM
Name*

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
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 arthritisI’m supporting someone who has axSpA/inflammatory arthritisOther
If diagnosed, what type of arthritis were you diagnosed with?

axSpAnr-axSpAASPsARAIBD-associated arthritisOther
When were you diagnosed (month/year)?

MonthDayYear
Date
Are you currently under medical care for this condition?

YesNoInfrequently
What treatments are you currently doing or have recently done for your condition?

Medication (e.g., NSAIDs, biologics)Physical therapyExercise/movement routinesStrength trainingStretching/flexibility programsYogaDiet or nutrition changesSupplementsManual therapy (e.g., massage, chiropractic)AcupunctureMindfulnessStress-reduction practicesI'm not currently doing any treatmentOther
What are the main physical symptoms you're currently dealing with?

StiffnessPainFatigueReduced mobilityMuscle weaknessJoint swellingGut issues (e.g. bloating, constipation, IBD)Sleep disturbanceAnxiety/depressionOther
Where in your body do you experience the most symptoms?

NeckUpper backLower backSacroiliac joints (hips/pelvis)HipsKneesShouldersWristsAnklesFeetChest/ribsGutOther
How would you describe your current mobility level?

Fully mobile and independentMostly mobile but with limitationsMobile with assistive devicesLimited mobility and require assistance
What physical activities do you currently do (if any)?

WalkingYogaStretchingStrength trainingSwimmingCyclingNone currentlyOther
What are your top 3 health goals?
Which of these areas would you most like to improve?

StrengthFlexibilityPain managementStress reductionNutritionGut healthDaily habits/routinesSleepMind-body connectionOther
On a scale from 1 to 5, how ready do you feel to make changes to your health and routine right now?

1

2

3

4

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?

InstagramTik TokYouTubeFacebookPodcastFriend or family referralSupport group or forumGoogle searchNewsletter or emailIn-person event or talkMy healthcare providerOther
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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