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NEW CHAPTER COACHING
Strength & Longevity Coach
Build Strength. Move Better. Live Longer.  |  @NEWCHAPTERCOACHINGLC
1. Personal Details
2. Health & Medical Screening

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

Diabetes
Heart Problems
High Cholesterol
Arthritis
Stroke
Asthma
High Blood Pressure
Low Blood Pressure
Chest Pain / Angina
Epilepsy
Osteoporosis
Cancer
Yes No If yes, how many per day?
Yes No If you stopped, how long ago?
Yes No
3. Injury Profile

Have you ever injured any of the following areas?

Head
Neck
Back / Spine
Shoulders
Arms / Elbows
Hands / Wrists
Hips
Upper Legs
Knees
Lower Legs / Shins
Ankles / Feet
Torso / Ribs
Yes No
4. Physical Profile
5. Goals & Coaching Focus

I want to… (tick all that apply)

Get Stronger – Functional strength & muscle
Get Fitter – Cardiovascular fitness
Build Muscle – Lean muscle mass
Lose Body Fat – Improve body composition
Move Better – Mobility & flexibility
Learn to Swim – Lessons & technique
Improve Nutrition – Healthy eating habits
Reduce Pain – Manage chronic pain
Train for an Event – Race, competition, milestone
Longevity & Healthspan – Age well, stay independent
Not very Somewhat Very Extremely
Exercise Nutrition Stress / Mood Sleep / Recovery
6. Lifestyle Baseline

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

7. Motivation & Support
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
Family Friends Partner Work Colleagues
8. Exercise History & Preferences

If you are CURRENTLY exercising:

If you have PREVIOUSLY exercised:

9. Nutrition Basics
10. Coach Assessment Notes

Movement Assessment Findings:

Intervention Strategy:

What to do:

How soon:

What to discuss:

Referral / Prescription Notes:

11. Informed Consent
I confirm that the health & personal information provided above is, to the best of my knowledge, accurate and complete.
I will inform my New Chapter Coaching coach immediately of any changes to my health status, medications, or physical condition.
I understand that participating in physical activity & exercise carries inherent risks, and I voluntarily accept all responsibility for those risks.
I understand that due care and professional judgment will be exercised by my New Chapter Coaching coach at all times.
I consent to my coach recording and storing my personal and health data in accordance with privacy regulations, for the sole purpose of delivering my coaching programme.
New Chapter Coaching  |  Build Strength. Move Better. Live Longer.  |  @NEWCHAPTERCOACHINGLC
Programme Start Date:    Review Date:    Coach: Luis Carlos