Client Intake Form

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Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Please enter a valid phone number.
4
Date of Birth* This field is required.
Date
Year
Month
Day
5
Gender* This field is required.
Male
Female
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What is your height?* This field is required.
7
What is your weight?* This field is required.
8
Please list any previous or current injuries. * This field is required.
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9
What are your fitness goals?
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New Member Photo* This field is required.Please upload a picture of yourself for our new members board!
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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For New Members Board: Tell us a little about yourself... What are your interests and hobbies outside of fitness? Do you have any dogs or pets? Favorite sports team?
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Do you currently have a support system to help you achieve those goals?* This field is required.
YESNO
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What has been your biggest obstacles in achieving these goals, and are any of them still present?* This field is required.
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How do you typically handle challenges or setbacks in your fitness routine?* This field is required.
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How passionate are you about achieving your goals?
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How many days a week do you plan on committing to achieve your goals?* This field is required.
1
2
3
4
5 or more
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What are you currently doing for fitness?
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Are you currently a member at another gym. If yes, which one?
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What do you feel is missing from your current routine. Check all that apply.
Cardiorespiratory Training
Resistance Training
Flexibility Training
Plyometric Training
Core Training
Balance Training
Strength Training
Speed, Agility, Quickness Training
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What are you looking for in a coach and training program?* This field is required.
21
If female, are you currently pregnant?
Yes
No
22
Please list any physical disabilities. If none, skip the question.
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Music is a big part of our training - what is your favorite type of music? Any artist you like to listen to while training?
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Do you have a heart condition?* This field is required.
YESNO
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Do you currently take any medication that would affect your heart rate or blood pressure?* This field is required.
YESNO
26
Do you feel any chest pain while participating in physical activity?* This field is required.
YESNO
27
If you answered yes to any of the above questions, have you received permission from your physician to participate in physical activity?
YESNO
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I, blanks * , agree that I have read and answered the above questions to the best of my ability. If there are any inaccuracies, knowingly or unknowingly, in answering questions about my health, Blitz45 Fitness and Echols Family Fitness, LLC., cannot be held responsible. I am assuming the risk in partaking in physical fitness at the Blitz45 Fitness in Little Elm, TX location.
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Signature * This field is required.
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