Blue Light Intake Form
Full Name
First Name
Last Name
What is your age?
What is your gender?
Please Select
Male
Female
N/A
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Check the symptoms that you' re currently experiencing:
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
Other
Are you currently taking any medication?
Yes
No
Please list them.
Do you have any medication allergies?
Yes
No
Not Sure
What is your height?
What is your current weight?
What is your primary fitness goal in joining our gym? (Specific)
Do you have any past injuries or medical conditions we should be aware of?
How many days per week can you realistically commit to training?
1-2 Days
2-3 Days
3-4 Days
4+ Days
What type of support do you feel you need most to help you reach your goals? (e.g., coaching, nutrition guidance, accountability)
What is your current experience with CrossFit or functional training?
Brand New
Some Experience (6-12 months)
Experienced (1+ years)
Experienced but it's been awhile (more than 6+ months since training)
Do you feel comfortable using barbells for lifts like squats, deadlift, and press?
Yes, confident and consistent
Somewhat, I'd like more practice
Not yet, I'd like to learn from scratch
Are you currently recovering from or working through an injury, surgery, or chronic pain?
Are there any barriers or considerations we should know to help you succeed? (work schedule, old injuries, motivation issues, confidence)
Are you currently working with a physical therapist, doctor, or medical provider for an injury or surgery recovery? (if yes, please explain)
If you are recovering from an injury or surgery, would you like our team to coordinate with your medical provider to ensure you're progressing safely?
Yes, please connect with my PT/Doctor.
No, I'm okay managing it myself.
NA, does not apply.
Are you experiencing any ongoing pain or limitations in your range of motion that hold you back in workouts? (if yes, please explain)
Do you prefer training in a larger class environment (10-15 people) or smaller group (4 people) with more personalized training?
Large group/general CrossFit sessions
Small group/specific focus personalized training
Would you benefit from a structured program that focuses on safe movement patterns and building foundational strength after recovery?
Yes, I want to rebuild confidence in movement.
No, I can learn in a large group setting.
What is your primary fitness goal right now? (Choose the one that best describes your focus)
Build total body strength and learn solid technique (Strong Foundation)
Burn fat, improve endurance, and feal leaner (Lean & Conditioned)
Move pain-free, improve mobility, and strengthen stabilizing muscles (Bulletproof Movement)
Ease back into exercise after time off, injury, or surgery (Back on Track)
Prepare for or return to CrossFit style workouts (Stronger for CrossFit)
Learn or refine barbell lifts (squat, deadlift, press, cleans) (Barbell Basics)
Get back into it, straight to CrossFit classes.
Do you have any current limitations (pain, tightness, previous injuries) that affect how you move?
No, I'm moving well and ready for class.
Yes, I'd benefit from corrective work or joint friendly modifications (Bulletproof Movement/Back on Track)
Somewhat, I'm moving okay but I need to rebuild strength and stability (Strong Foundations/Bulletproof Movement)
No limitations, but I'm looking to build intensity. (Lean & Conditioned/Stronger for CrossFit/Barbell Basics)
Are you more interested in smaller, more personalized groups for high energy workouts, skill development, or movement quality?
No, I love the bigger CrossFit classes (10-15 people)
Smaller groups with High Energy/Sweat and Intensity (Lean and Conditioned)
Smaller groups for Skill Development (lifting, technique, performance) (Barbell Basics, Stronger for CrossFit)
Smaller groups focused primarily on Movement Quality (mobility, control, pain free training) (Bulletproof Movement/Back on Track)
What does a successful training experience look like for you in the next 3-6 months?
Submit
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