Training + Nutrition Intake

Client Information

Full Name *

Preferred Name

Email *

Phone Number *

Date of Birth *

Gender

Height & Weight

Emergency Contact (Name & Phone)

Coaching Logistics

How did you hear about Habit Fitness?

Social Media Referral Website Other

Preferred method of communication

Email Text

Best days/times for check-ins

Fitness & Lifestyle Goals

What are your primary goals? (Check all that apply)

Fat loss Muscle building Strength Endurance Habit-building / consistency Postpartum recovery General health & energy Improve performance

Describe your goals in your own words

What does success look like for you in 3 months?

Do you have a specific goal date or timeline?

Current Activity Level

Current fitness level

Beginner Intermediate Advanced

Days per week you currently exercise

0 1-2 3-4 5+

Types of activity you currently do (if any)

Strength training Cardio Classes Sports Walking

Workout Preferences

How many days per week would you LIKE to work out?

Preferred workout length

Training Environment & Equipment

Where will you primarily be training?

Commercial gym Home gym Both

If using a gym, gym name or website link

If training at home, list your equipment (dumbbells, barbell, resistance bands, etc.)

Any equipment limitations I should know about?

Injury & Medical History

Have you ever been injured due to exercise?

No Yes

If yes, please explain

Do you currently have pain, injuries, or physical limitations?

No Yes

If yes, location & details

Have you been diagnosed with any of the following? (Check all that apply)

Heart condition High blood pressure Diabetes / blood sugar issues Thyroid condition Joint or back issues Eating disorder history

Other medical conditions

Are you currently under a physician's care?

No Yes

Medications that may affect exercise (if any)

Pregnancy & Postpartum (if applicable)

Are you currently pregnant?

No Yes

If yes, trimester

1st 2nd 3rd

Are you postpartum?

No Yes

If yes, how many months postpartum?

Have you been cleared by your healthcare provider to exercise?

Yes No N/A

Nutrition & Lifestyle

These questions help me build nutrition guidance that fits your real life. If nutrition is not part of your coaching plan, you may leave optional questions blank.

Current nutrition consistency

Very inconsistent Somewhat consistent Very consistent

Dietary preferences or restrictions

None Vegetarian Vegan Gluten-free Dairy-free Other

Food allergies or intolerances

Foods you dislike or avoid

Describe a typical day of eating

Food or macro tracking experience

None Some experience Comfortable with tracking

Past diets or approaches you have tried

Supplements currently used

Digestive issues or concerns

Average sleep per night

<6 hrs 6-7 hrs 7-8 hrs 8+ hrs

Current stress level

Low Moderate High

Barriers & Support

What has stopped you from reaching your goals in the past?

What are your biggest nutrition challenges right now?

What kind of support helps you most?

Accountability Education Encouragement Structure Flexibility Frequent check-ins Mindset support

Anything else you want me to know?

Habit Change Focus

List the top 5 habits you want to change, build, or improve through coaching. (Examples: daily steps, consistent workouts, protein intake, sleep routine, hydration, mindset practices)

Habit 1

Habit 2

Habit 3

Habit 4

Habit 5

Acknowledgment & Consent

By submitting this form, I confirm that the information provided is accurate to the best of my knowledge. I understand that Habit Fitness provides fitness and nutrition coaching and education only and does not provide medical advice, diagnosis, or treatment. If nutrition coaching is part of my plan, I understand that it focuses on macro and calorie tracking rather than individualized meal plans. I agree to notify my coach of any changes to my health status.