Strong Bones Blueprint Pre-Evaluation Form

Your answers are used only to review whether Strong Bones Blueprint is a good fit for you and to contact you about it. They are seen only by your instructor and stored securely in Tally and Notion. Your name and email may also be kept in a contact list so I can follow up. Answers are deleted when no longer needed. Please don't share diagnoses, test results or medication names in the text boxes. We'll go through your history together at your baseline assessment. Full privacy policy: https://www.bonehealthcomox.com/legal#privacy

Has your doctor cleared you for exercise?

Yes

Haven't asked yet

How did you hear about Strong Bones Blueprint?

Which days/times could you attend a twice-weekly in-person class?

Please rate your current level of physical activity.

Have you experienced any non-traumatic fractures (e.g., a fall from standing height) in the past 5 years?

Yes

Do you have any pre-existing medical conditions that may limit your ability to perform high-load exercises?

Severe joint pain/Arthritis (e.g., Hip or Knee)

Uncontrolled High Blood Pressure

Severe back pain/Spinal conditions

Balance issues/Risk of falls

Cardiovascular disease

None of the above

On a scale of 1 to 5, how motivated are you to commit to a regular, structured exercise program?

Which of the following describes your current pain levels (in general)?

When would you prefer to start Strong Bones Blueprint?

Immediately (Next 1-2 weeks)

Within the next month

Within the next 3 months

Just gathering information for now

Is there anything else we should know regarding your health or fitness before the official assessment?

Optional. Please don't include diagnoses, test results or medication names here. We'll cover those at your assessment.

Email

Full Name

In a sentence, what's the main thing you'd like to be able to do?

No need to include diagnoses or test results.

Do you have a current diagnosis of Osteoporosis or Osteopenia?

Yes, Osteoporosis

Yes, Osteopenia

No, but concerned about bone health

Have you had a recent (within the last 2 years) Bone Mineral Density (BMD) scan (e.g., DEXA, REMs scan)?

Yes

Scheduled soon

Have you had a fall in the past year?

Yes

Are you currently taking a bone-specific medication prescribed by your doctor?

Yes

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I agree to Bone Health CV collecting the information in this form to review whether the program is a good fit for me and to contact me about it.

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Send me the Bone Health CV newsletter and occasional updates. I can unsubscribe at any time.

	3:45–4:30 pm	5:00–5:45 pm
Monday
Tuesday
Wednesday
Thursday

	None	Mild	Moderate	Severe
Joint Pain (Average)
Back Pain (Average)
Overall Body Aches