Kiva Movement Intake Form

Welcome!

Let's start with your name

What's your first name? *

Please enter your first name

What's your last name? *

Please enter your last name

What brings you here?

Let's start with your primary goal

What's your primary goal right now? *

Move without pain Improve mobility/flexibility Get back to a sport/activity Prevent injury Improve performance General fitness

Please select your primary goal

Your current state

Let's understand what's happening with your body

Are you currently dealing with any discomfort or limitation? *

Yes No

Please select an option

Where's the issue?

Select all areas where you're feeling discomfort — we'll walk through each one

Where are you feeling discomfort or limitation? *

Neck Shoulders Upper back Lower back Hips Knees Ankles / Feet

Please select at least one region

Neck Assessment

Question 1 of 8

Where in your neck? *

Base of neck Side of neck Upper neck / base of skull Not sure

Neck Assessment

Question 2 of 8

What does it feel like? *

Sharp pain Dull ache Stiffness Weakness Tightness

Neck Assessment

Question 3 of 8

When do you notice it most? *

Looking down Screen time Driving Sleeping Turning head After activity First thing in the morning

Neck Assessment

Question 4 of 8

Does anything make it better? *

Rest Stretching Movement Heat / ice Not sure

Neck Assessment

Question 5 of 8

Do you also get headaches? *

Yes No

Neck Assessment

Question 6 of 8

Are you also feeling issues in nearby areas? *

Shoulders Upper back Both None

Neck Assessment

Question 7 of 8

What activities is this limiting? *

Neck Assessment

Question 8 of 8

How long has this been going on? *

A few days A few weeks A few months Over 6 months

Shoulders Assessment

Question 1 of 8

Which part of your shoulder? *

Front Top Back Deep inside Not sure

Shoulders Assessment

Question 2 of 8

What does it feel like? *

Sharp pain Dull ache Stiffness Weakness Catching/clicking

Shoulders Assessment

Question 3 of 8

When do you notice it most? *

Overhead movement Lifting Reaching behind back Sleeping on it Pushing/pulling After activity First thing in the morning

Shoulders Assessment

Question 4 of 8

Does anything make it better? *

Rest Stretching Movement Heat / ice Not sure

Shoulders Assessment

Question 5 of 8

Do you have range of motion limitation? *

Yes No

Shoulders Assessment

Question 6 of 8

Are you also feeling issues in nearby areas? *

Neck Upper back Both None

Shoulders Assessment

Question 7 of 8

What activities is this limiting? *

Shoulders Assessment

Question 8 of 8

How long has this been going on? *

A few days A few weeks A few months Over 6 months

Upper Back Assessment

Question 1 of 7

What does it feel like most? *

More stiffness More pain Both equally Not sure

Upper Back Assessment

Question 2 of 7

What does it feel like? *

Sharp pain Dull ache Stiffness Tightness Breathing feels restricted

Upper Back Assessment

Question 3 of 7

When do you notice it most? *

Sitting at desk Poor posture Deep breathing Twisting/rotating After activity First thing in the morning

Upper Back Assessment

Question 4 of 7

Does anything make it better? *

Rest Stretching Movement Heat / ice Not sure

Upper Back Assessment

Question 5 of 7

Are you also feeling issues in nearby areas? *

Neck Shoulders Lower back None

Upper Back Assessment

Question 6 of 7

What activities is this limiting? *

Upper Back Assessment

Question 7 of 7

How long has this been going on? *

A few days A few weeks A few months Over 6 months

Lower Back Assessment

Question 1 of 8

Where exactly? *

Center of lower back One side Both sides Not sure

Lower Back Assessment

Question 2 of 8

What does it feel like? *

Sharp pain Dull ache Stiffness Weakness Radiating pain (down leg)

Lower Back Assessment

Question 3 of 8

When do you notice it most? *

Bending over Lifting Sitting for long periods Standing for long periods Walking After activity First thing in the morning

Lower Back Assessment

Question 4 of 8

Does anything make it better? *

Rest Stretching Movement Heat / ice Not sure

Lower Back Assessment

Question 5 of 8

Do you have radiating symptoms (pain/tingling down your leg)? *

Yes No

Lower Back Assessment

Question 6 of 8

Are you also feeling issues in nearby areas? *

Hips Upper back Both None

Lower Back Assessment

Question 7 of 8

What activities is this limiting? *

Lower Back Assessment

Question 8 of 8

How long has this been going on? *

A few days A few weeks A few months Over 6 months

Hips Assessment

Question 1 of 8

Where in your hip? *

Front of hip Side of hip Glute / back of hip Not sure

Hips Assessment

Question 2 of 8

What does it feel like most? *

More tightness More pain Both equally Not sure

Hips Assessment

Question 3 of 8

What does it feel like? *

Sharp pain Dull ache Stiffness Tightness Weakness

Hips Assessment

Question 4 of 8

When do you notice it most? *

Walking Sitting for long periods Going up stairs Squatting Crossing legs After activity First thing in the morning

Hips Assessment

Question 5 of 8

Does anything make it better? *

Rest Stretching Movement Heat / ice Not sure

Hips Assessment

Question 6 of 8

Are you also feeling issues in nearby areas? *

Lower back Knees Both None

Hips Assessment

Question 7 of 8

What activities is this limiting? *

Hips Assessment

Question 8 of 8

How long has this been going on? *

A few days A few weeks A few months Over 6 months

Knees Assessment

Question 1 of 7

Which part of your knee bothers you most? *

Front Inside Outside Back Not sure

Knees Assessment

Question 2 of 7

What does it feel like? *

Sharp pain Dull ache Stiffness Weakness Instability (feels like giving out)

Knees Assessment

Question 3 of 7

When do you notice it most? *

Walking Running Going downstairs Squatting / bending Sitting for long periods After activity First thing in the morning

Knees Assessment

Question 4 of 7

Does anything make it better? *

Rest Stretching Movement Heat / ice Not sure

Knees Assessment

Question 5 of 7

Are you also feeling issues in nearby areas? *

Hip Ankle Both None

Knees Assessment

Question 6 of 7

What activities is this limiting? *

Knees Assessment

Question 7 of 7

How long has this been going on? *

A few days A few weeks A few months Over 6 months

Ankles & Feet Assessment

Question 1 of 8

Where is the issue? *

Ankle Heel Arch Top of foot Not sure

Ankles & Feet Assessment

Question 2 of 8

What does it feel like? *

Sharp pain Dull ache Stiffness Weakness Instability

Ankles & Feet Assessment

Question 3 of 8

When do you notice it most? *

Walking Running Standing for long periods Going up/down stairs After activity First thing in the morning

Ankles & Feet Assessment

Question 4 of 8

Does anything make it better? *

Rest Stretching Movement Heat / ice Not sure

Ankles & Feet Assessment

Question 5 of 8

Do you have stiffness in the morning? *

Yes No

Ankles & Feet Assessment

Question 6 of 8

Are you also feeling issues in nearby areas? *

Knees Hips Both None

Ankles & Feet Assessment

Question 7 of 8

What activities is this limiting? *

Ankles & Feet Assessment

Question 8 of 8

How long has this been going on? *

A few days A few weeks A few months Over 6 months

Your movement & lifestyle

Help us personalize your plan further

How active are you currently? *

Not active Light activity (walking, occasional workouts) Moderate (2–3x/week) Very active (4–5x/week or sports)

Please select your activity level

What activities do you enjoy or want to get back to?

How would you rate your mobility/flexibility?

Poor Fair Good Excellent

How much time can you realistically commit? *

5 minutes/day 10 minutes/day 15+ minutes/day

Please select a time commitment

Your success definition

What does success look like for you?

What would success look like for you? *

Please tell us what success looks like for you

Kiva Movement Intake

You're all set!