Nutrition Intake Form | Habit Fitness

Client Information

Full Name *

Email *

Phone Number

Date of Birth

Height & Weight

What are your main nutrition goals? (Check all that apply)

Fat loss Muscle gain Improve energy Consistent habits Performance General health

Describe your goals in your own words

Ideal timeline for these goals

Current nutrition consistency

Very inconsistent Somewhat consistent Very consistent

Dietary preferences

None Vegetarian Vegan Gluten-free Dairy-free Other

Food allergies or intolerances

Foods you dislike or avoid

Describe a typical day of eating

Tracking experience

None Some experience Comfortable with tracking

Any past diets or approaches you've tried?

Supplements currently used

Water intake

Low Moderate High

Alcohol frequency

None Occasionally Weekly

Digestive issues

Biggest challenges with nutrition right now

What kind of support helps you most?

Accountability Education Structure Flexibility Frequent check-ins Mindset support

Anything else you want me to know?