INTAKE FORMINTAKE FORMINTAKE FORMINTAKE FORM RDCOACHINGStep 1 of 714%Client personal informationName First Last Date of birth MM slash DD slash YYYY E-mailadres: Billing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneTraining and fitnessPlease shortly describe your fitness and sport specific goals:On a scale from 1-10, how important is this for you? 1 6 2 7 3 8 4 9 5 10How many times a week can/will you train?Where do you normally train? Gym Home Outside gym area OtherDo you practice other physical activities besides fitness? Yes NoWhich ones?Do you have specific exercises you definitely CANNOT do?Do you have specific exercises you definitely WANT to do?Please describe your past or current trainingsplan as accurate as possible:What kind of materials/machines are available in your own gym? If you're unsure, you can look them up on Google Squat rack Dumbbells till 50 kg Chin up belt Safety squat rack Dumbbells till 40 kg Straps Smith Machine Dumbbells till 30 kg Plates <1,25 kg Trap bar Kettlebells till 4 kg Mini bands Glute ham raise machine Kettlebells till 6 kg Gymnastic rings Reverse hyper machine Kettlebells till 8 kg Leg extension A cable station Kettlebells till 12 kg Resistance bands An adjustable cable station Kettlebells till 24 kg TRX 45° hyperextension bench Kettlebells till 32+ kg Heavy chains Standing calf raise Seated Leg Curl Machine Stopwatch Seated calf raise Lying Leg Curl Machine Sissy Squat Standing Leg Curl MachineMedical HistoryDo you use medication? Yes NoWhat kind of medication do you use and for what?Do you have any allergies or intolerances? Yes NoHas this been diagnosed by a medical professional? Yes NoIf yes, what kind of medical professional?Do you suffer from any current or past injuries? Yes NoWhat kind of injuries?Do you have a physical handicap? Yes NoIf yes, what kind of physical handicap?Are you currently diagnosed or have you previously suffered from any mental disorders? Yes NoIf yes, what kind of mental disorder?NutritionDo you have a well-defined knowledge of your nutrition over the past few months? Yes NoPlease indicate whether you experienced the following? Weight loss Maintenance or stable weight Weight gainCan you give me an estimated daily calorie count for weight loss?Can you give me an estimated daily calorie count for maintenance?Can you give me an estimated daily calorie count for weight gain?On average, how much protein do you consume daily?What can you change about your eating habits?Do you eat the recommended amount of vegetables and fruits (250 grams) daily ? Yes NoDo you prepare your own food, or are you dependent on others to cook (family, friends, partner etc.)?Do you go out for dinner? Yes NoHow often?Do you drink alcohol? Yes NoHow much and how often?Are you open to the idea of tracking your calories? Yes NoAre you open to the idea of weighing yourself daily? Yes NoDaily life and sleep scheduleDo you have small kids (up to age 8)? Yes NoWhat does your daily life look like (job, school, etc.) ?Please indicate your level of stress on a scale from 1-10 1 6 2 7 3 8 4 9 5 10How many hours do you sleep a night on average?Please describe your regular sleep schedule:What do you do an hour before you go to sleep?Do you wake up feeling tired? Yes NoDo you take naps during the day? Yes NoDo you experience many “broken nights”? Yes NoIf yes, how many times per week?SignatureHow did you find RDCOACHING? Our website Instagram Facebook Recommended by others (friends, family, colleagues etc.) OtherWhy did you choose RDCOACHING?The information provided on this intake form is strictly confidential between Client and RDCOACHING and will not be shared without mutual consent. By checking the following box I state that I have truthfully answered this intake form to the best of my abilities and that I agree to the terms and conditions of RDCOACHING.(Required) YesDate(Required) MM slash DD slash YYYY