EK⚡TREME Training Health & Fitness Intake
Please complete this intake form to help us tailor your training and guidance. All information is confidential.
Basic Information
Tell us about yourself.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Height (please specify units)
*
Current Weight (please specify units)
*
Primary Goal
*
Fat Loss
Muscle Gain
Strength
Endurance
General Fitness
Training Experience
*
Beginner
Intermediate
Advanced
Activity Level
*
Sedentary
Lightly Active
Moderately Active
Very Active
Medical History (check all that apply)
*
Heart condition
High blood pressure
Low blood pressure
Diabetes
Asthma
Joint problems
Dizziness during exercise
Chest pain during exercise
Seizures
Food allergies
Supplement sensitivities
None
If you selected any medical conditions above, please explain.
Are you currently taking any medications?
Yes
No
Please list your current medications.
Supplement Sensitivities (check all that apply)
Caffeine
Creatine
Beta-Alanine
Protein powders
Artificial sweeteners
None
Have you had any injuries?
Yes
No
Please explain your injury history.
Physician Clearance
*
I have consulted a physician
I have chosen not to and accept responsibility
Nutrition Habits
Your eating habits help us guide your plan.
How would you rate your diet quality?
*
Poor
Fair
Good
Very Good
Excellent
How many meals do you eat per day?
*
How much water do you drink per day? (specify amount & units)
*
Sleep & Stress
Tell us about your rest and stress levels.
Average sleep hours per night
*
How would you rate your stress level?
*
Low
Moderate
High
Acknowledgment
*
I confirm this information is accurate and understand this is for fitness guidance, not medical advice. I hereby release, waive, and discharge Ekstreme Power Fitness LLC, its owners, coaches, and representatives from any liability for injury, illness, allergic reaction, disability, or death arising from my participation or supplement use, including negligence.
Digital Signature (type your name)
*
Date
*
-
Month
-
Day
Year
Date
Submit Intake Form
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