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21-Day Challenge
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21-Day Challenge
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Client Intake Form
PLEASE TAKE A MOMENT & COMPLETE THIS INTAKE FORM BEFORE YOUR NEXT WORKOUT
FULL NAME
ADDRESS
DATE OF BIRTH
SEX
(Required)
FEMALE
MALE
HEIGHT & WEIGHT
(Required)
PHONE
(Required)
EMAIL
(Required)
Emergency Contact Name
Emergency Contact Number
Have you ever been to (((BLAZE FITNESS)))?
(Required)
Yes
No
Is BLAZE conveniently located for you?
(Required)
Yes
No
How did you hear about us?
(Required)
Word of mouth
Social Media
Member Referral
Other
What days do you prefer to work out? (Give 2-3 Options)
(Required)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What times of day do you prefer?
(Required)
Morning
Noon
Afternoon
All of the above
How often do you currently work out?
(Required)
None
1-2 Times A Week
3-5 Times A Week
What are your personal fitness goals?
(Required)
Weight/Fat Loss
Improve Overall Health
Variety
Athletic Performance
Fitness Goals
(Required)
What were you doing when you were your most physically active?
(Required)
On a scale of 1 to 10, how passionate are you about achieving your fitness goals?
(Required)
What obstacles have you faced in achieving your fitness goals in the past?
(Required)
Do you have the support of the people close to you?
(Required)
Name 2 friends who would hold you accoutable!
Do you have any exercise restrictions/injuries our instructors should know about?
(Required)
Do you have any questions for me?
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