New Chapter Coaching – Client Consultation Form (Fillable)

Kia ora! 👋 One step before we start:
Please fill in this consultation form on your phone or computer — everything saves automatically as you type. When you're done, tap Print / Save PDF (choose "Save as PDF") and send the file back to Coach Luis on WhatsApp: 027 431 4263. It takes about 10 minutes.

1. Personal Details

Full Name

Date of Birth

Email Address

Mobile Number

Occupation

Gender

Emergency Contact Name

Emergency Contact Number

2. Health & Medical Screening

Have you or your direct family had any of the following?

If any checked, please provide details

Do you smoke?

Yes No If yes, how many per day?

Have you ever smoked?

Yes No If you stopped, how long ago?

Do you take any pills, tablets, or medication?

Yes No

If yes, please describe

3. Injury Profile

Have you ever injured any of the following areas?

Anything else that may affect your ability to exercise?

Yes No

4. Physical Profile

Height (cm)

Weight (kg)

BMI

Waist (cm)

Hip (cm)

W:H Ratio

Blood Pressure

Resting Heart Rate

5. Goals & Coaching Focus

I want to… (tick all that apply)

How important is it that you achieve these goals?

Not very Somewhat Very Extremely

What areas are you willing to work on?

Exercise Nutrition Stress / Mood Sleep / Recovery

6. Lifestyle Baseline

Rate each on a scale of 1–10 (1 = low/poor, 10 = high/excellent)

Physical Activity Level

Sleep Quality

Stress Level

Nutrition Quality

Energy Levels

Overall Wellbeing

7. Motivation & Support

Which phrase best describes your motivation?

I am self-motivated – I stick to plans on my own

I need regular motivation & accountability

I find exercise easier with a training partner

I do best with scheduled appointments

I sometimes struggle to stay consistent

Who is supportive of you achieving your goals?

Family Friends Partner Work Colleagues

What are you expecting from your coach at New Chapter Coaching?

8. Exercise History & Preferences

How many times per week do you currently exercise?

On a scale of 1–10, rate your current effort during exercise?

If you are CURRENTLY exercising:

What activities are you doing?

What do you like about them?

Is there anything you don't like?

If you have PREVIOUSLY exercised:

What activities did you do?

What did you like about them?

Was there anything you didn't like?

How long would you like each session? (minutes)

Preferred intensity (1–10)?

9. Daily Meal Log

Log everything you eat and drink. Be honest — this helps build a nutrition plan that works for you.

Day	Meal	What I Ate / Drank	Time	Hunger (1–10)
Mon	Breakfast
	Lunch
	Dinner
	Snacks
	Drinks
Tue	Breakfast
	Lunch
	Dinner
	Snacks
	Drinks
Wed	Breakfast
	Lunch
	Dinner
	Snacks
	Drinks
Thu	Breakfast
	Lunch
	Dinner
	Snacks
	Drinks
Fri	Breakfast
	Lunch
	Dinner
	Snacks
	Drinks
Sat	Breakfast
	Lunch
	Dinner
	Snacks
	Drinks
Sun	Breakfast
	Lunch
	Dinner
	Snacks
	Drinks

Food allergies, intolerances, or dietary restrictions?

Typical daily water intake (glasses / litres)?

Any supplements you currently take?

10. Coach Assessment Notes

Movement Assessment Findings:

Intervention Strategy:

What to do:

How soon:

What to discuss:

Referral / Prescription Notes:

11. Informed Consent

Client Name

Client Signature

Date