Name
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First Name
Last Name
Email Address
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Cell phone
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Age
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Height
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Weight
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What are your goals? Select all that apply.
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What are your trouble spots, where you tend to store excess body fat?
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List all of your concerns about your health, eating habits, fitness, and or body.
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Of the items you listed above, which feels the most important or urgent?
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What do you expect from me, as your coach?
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Have you tried things in the past to change your habits, your health, your eating, and/ or your fitness? If so, what?
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Of the things you've tried in the past, which one/s worked and which ones didn't?
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Have you already made changes to your habits, your health, your eating, and / or your body recently? If so, what?
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Until now, what has blocked you or held you back from changing these things?
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How many hours per week are you currently active in some form of exercise or sports activity?
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What types of sports, exercise and/or activity do you usually do, if any?
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If you've been following a workout program, please write it out here. Otherwise, just skip to the next question!
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Who lives with you?
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Who does the grocery shopping and cooking?
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Right now, how much do the people and things around you support health, fitness, and / or behavior change?
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If you have any food allergies or other nutritional concerns, please explain below.
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How many hours of sleep do you get per night?
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What time do you go to bed?
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What time to you get up?
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How's the quality of your sleep?
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How many servings of alcohol do you drink per week?
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How many servings of caffeine do you have per day?
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How much time do you spend outside most days?
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If you have been diagnosed (currently or in the past) with any significant medical condition(s) and / or injuries, please explain:
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Right now, do you have any specific health concerns, such as illnesses, pain, and / or injuries?
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List all medications and supplements you take regularly:
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How frequently do you do something you find relaxing or fun?
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How stressful is your job or daily life?
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Do you frequently eat on the run?
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Select any of the following digestive symptoms you experience regularly:
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Select the following metabolic disfunction symptoms you experience regularly:
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Select the following inflammation symptoms you experience regularly:
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Select any the following measures you regularly take to avoid toxic exposures.
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After submitting this form, please take 3 progress photos and email them to me at shannon.dahlum@gmail.com. Wearing a bathing suit, or something similar, stand relaxed and take photos from the front, side, and back.
Before our initial consultation, I need you to complete a 3 day food and sleep journal. Without changing what you normally eat, record everything you eat and drink, as well as what times you eat them. Also record what time you go to sleep and wake up, and how well you slept. You can email this to me or bring it with you to our meeting.
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I understand that Shannon Dahlum is not licensed, certified, or registered as a healthcare provider in the state of Louisiana. Any recommendations or advice given by her is not to be taken as medical advice, diagnosis, or treatment. I understand that it is my responsibility to clear all nutrition, training and lifestyle changes through my own medical doctor.
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Please type your full name in the box below, as your signature of acknowledgement of the above statement.
