Movement & Pain Screening — Abed Fit Coach

Section A

Personal information

Full name *

WhatsApp number *

Email address *

Date of birth *

Height (cm)

Weight (kg)

City / location *

How did you find Abed Fit Coach?

Instagram @abedfitcoach YouTube Referral teman / keluarga Google / artikel Dokter / fisioterapis Lainnya

Section B

Current pain & symptoms

Jawab dengan jujur — tidak ada jawaban yang salah. Ini supaya kami tahu kondisimu yang sebenarnya.

Do you currently have any pain or discomfort? *

Yes — I have ongoing pain or discomfort Sometimes — comes and goes No current pain, but I have a history of injury No pain or injury history

Where is the pain? (select all that apply)

Lower back / lumbar Neck / cervical Shoulder / scapula Knee(s) Hip / pelvis Ankle / foot / heel Wrist / elbow Other

Pain intensity at rest * 0 = no pain · 10 = worst imaginable

⚑ Pain guideline flag: Jika di atas 5/10, tim kami akan menghubungimu via WhatsApp sebelum konsultasi untuk menentukan langkah yang tepat.

Pain intensity during movement *

Does your pain have any of the following? * Centang semua yang berlaku

Radiates / travels down arm or leg Numbness (kebas / mati rasa) Pins & needles / tingling (kesemutan) Electric-shock sensation (seperti kesetrum) Sharp / stabbing (seperti diiris) None of the above

⚑ Neurological flag: Ini adalah red flag. Tim kami wajib menghubungimu sebelum konsultasi — kemungkinan perlu medical clearance dahulu.

What triggers or worsens the pain?

What relieves or reduces the pain?

Section C

Medical & injury history

Diagnosed conditions (select all that apply)

Lumbar disc herniation / HNP Osteoarthritis Patellofemoral pain syndrome Rotator cuff injury Achilles tendinopathy Plantar fasciitis Hypertension Diabetes / prediabetes Cardiovascular condition Osteoporosis / osteopenia Post-surgical Other

Surgeries or medical procedures

Current medications

Can you get up and down from the floor without assistance? *

Yes, independently Yes, but with support (wall, chair) Difficulty — need assistance Cannot do this currently

Section D

Movement & fitness background

Previous fitness activities (select all)

Weight training / gym Running / jogging Swimming Cycling Martial arts / combat sports Team sports Yoga / Pilates Walking as primary activity Never consistently active

How long away from structured exercise? *

Less than 6 months 6 months – 1 year 1 – 3 years 3 – 5 years More than 5 years Never had a consistent routine

Current weekly activity level

Mostly sedentary — desk work, minimal movement Light activity — occasional walking Moderate — intentional exercise 1–2x/week Active — regular exercise 3+x/week

Section E

Goals & expectations

What do you primarily want? (select up to 3) *

Reduce or manage chronic pain Get back to exercise safely Build functional strength Improve posture & movement quality Understand my body better Long-term independence & mobility Weight management Performance for a specific activity

What does success look like for you in 6 weeks? *Be specific — what would you be doing differently?

Preferred format *

Studio 1-on-1 (Surabaya) Online / virtual coaching Small group (studio, 2–4 orang) Belum tahu — ingin diskusi dulu

Section F

Terms & consent

Dengan mengirimkan checklist ini, saya menyatakan bahwa:

1. Semua informasi yang saya berikan adalah benar dan lengkap sesuai pengetahuan saya.

2. Saya memahami bahwa data kondisi saya akan digunakan oleh tim Abed Fit Coach untuk keperluan assessment, pengembangan program, dan konten edukasi anonim.

3. Saya bersedia membaca dan menandatangani Participation Agreement & Liability Waiver sebelum sesi pertama dimulai.

4. Saya memahami bahwa checklist ini bukan pengganti konsultasi medis. Tim Abed Fit Coach berhak merujuk saya ke dokter atau fisioterapis jika kondisi saya memerlukan medical clearance terlebih dahulu.

5. Saya membebaskan, melepaskan, dan menanggung sendiri segala risiko yang timbul dari keikutsertaan saya dalam program Abed Fit Coach / ForeverFit Indonesia, termasuk sesi studio, online, dan aktivitas mandiri berdasarkan panduan yang diberikan. Baca T&C lengkap →

Saya telah membaca, memahami, dan menyetujui pernyataan di atas. Saya bersedia membaca Participation Agreement & Liability Waiver lengkap sebelum sesi pertama. * Saya menyetujui penggunaan data kondisi saya secara anonim untuk keperluan pengembangan konten edukasi Abed Fit Coach.

Setelah submit, tim kami akan menghubungimu via WhatsApp dalam 24 jam untuk konfirmasi dan jadwal konsultasi gratis 20 menit.

No payment. No commitment. PA replies within 24 hours.