First Name
Last Name
Email
*
Phone
*
What are your primary lifestyle goals?
*
Continue to participate in my hobbies and passions (i.e. golf, pickleball, gardening, etc...)
Maintain independence (i.e. continue doing my own home tasks)
Continue to spend quality time with loved ones (i.e. children or grandchildren)
Get back to feeling the way I used to when I was younger
I have physically demanding job and my body is breaking down
Avoid the health problems that I saw my loved ones go through
Other
What are you primary health and wellness goals?
*
Improve the way I look and feel
Stress management and reduction
Weight management
Increase flexibility and mobility
Improve overall fitness levels
Improve functional strength
Manage or reduce pain
Where do you need the most help from ProActive's specialists?
*
Accountability
I don't know where or how to start
I've hit a plateau
I'm not sure
Other
How would you describe your current level of physical activity?
*
Sedentary (little or no exercise)
Lightly active (light exercise or sports 1-3 days/week)
Moderately active (moderate exercise or sports 3-5 days/week)
Very active (hard exercise or sports 6-7 days a week)
Super active (very hard exercise or sports, physical job, or training twice a day)
If your participation is lower than you would like it to be, what are the reasons?
*
Lack of time
Lack of motivation
Lack of accountability
Injury/pain
Other
What type of wellness services are you interested in?
*
Functional Strength Training
Semi-Private Classes (Strength and/or Mobility)
Medical Professional Run Semi-Private Gym
Full Body Redlight and Near Infrared Light Therapy
PEMF (Pulsed Electromagnetic Frequency)
Dry Needling
Custom Orthotics, Pillows and Shoes
Rate your willingness/readiness to start your journey to better health (1 not ready...10 extremely ready)
1-2
3-4
5-6
7-8
9-10 (I am ready to take a ProActive approach to my health)
Do you have any specific areas of concern or conditions you'd like to address?
Is there anything else you’d like us to know about your health or wellness journey?
By providing your phone number, you agree to receive marketing text messages and phone calls from ProActive Physical Therapy, including calls that may be automated, prerecorded, or use an AI-generated voice. These communications may include follow-ups regarding your inquiry, services, promotions, and scheduling. Consent is not a condition of purchase. Message and data rates may apply for text messages. You may opt out of receiving text messages at any time by replying STOP. You may opt out of phone calls at any time by requesting to be placed on our Do Not Call list during any call or by contacting our office directly.
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