The 1:1 Diet Personal Record Form

Personal Record Form

Please answer as much as you can. If you have any questions, please call Maria on 07935700751. The data here will be added to our online form and you will receive notification as soon as it has been submitted
1. Contact Details
First Name*
Last Name*
Street*
Town*
County*
Post Code*
Email*
example@example.com
Phone*
2. Personal Details
Age*
DOB*
Gender*
Occupation*
Height*
Weight*
Waist
BMI
Previous dieter?

YesNo
Typical weekly activity/exercise*

SedentaryModerateActive
Are you on any GLP1 medication
3. Medical Information
Contraindicated

Alcoholic/substance misuser within one year of recoveryAnti - obesity medicationSerious illness, trauma or surgery (within the last three months)Serious mental health episode ;such as schizophrenia, delusional disorder, psychotic episode, bi-polar disorder (within the last six months)Current active anorexia, bulimia or currently undergoing any treatment for any eating disorderHeart failure/attack, arrhythmia, valve disease requiring treatment (within the last three months)MAOI medicationStroke or TIA (within the last three months)Pregnant, breastfeeding or given birth in the last three months
Requires MEF

Diabetes Type 1Diabetes Type 2 (controlled by more than Metformin)Gastric surgical procedures (within one year)
Step 1B minimum & Monitoring letter

Kidney disease/failureLiver disease/failureMental health disorders (stable)Angina/Arrythmia (stable)GoutAnti-coagulant medication (such as warfarin)
Any step & monitoring letter

Cholesterol medicationDiabetes Type 2 (controlled by diet or metformin and/or sitagliptin)Diuretics (water tablets)Hypertension (high blood pressure)Thyroid medication
If you are on any Fertility Medication or have ticked any conditions in Step 1B & Monitoring letter sections. Please add your Doctors details below.
Step 4 minimum & Monitoring letter

Fertility medication
Step 3 minimum

Smoking cessation medication (such as Champix)Stomach ulcerKidney stones
Step 1B minimum

Cancer in remissionEpilepsyPorphyriaDiabetes InsipidusPsoriasisRheumatoid arthritis treated with medicationSpinal conditions Such as Sciatica, spondylitisis, scoliosis) treated with medicationNeuro/muscular conditions (such as MS, Fibromyalgia?AnaemiaAntibiotic medicationConstipationCrohn’s disease, ulcerative colitis, IBSDiverticular diseaseGall stonesPain relief (moderate to strong)Vertigo
Or

None Apply
Any other medical conditions or medications:
Any allergies or intolerances:
4. Client Deceleration

Please confirm the following and sign the declaration:
1. The information given is correct and I have been advised to consult my GP before starting any weight loss programme.

2. I understand the importance of following the selected Step according to directions given by my consultant and additional literature supplied my CWP.

3. If my health status/medication changes while using any CWP step, I agree to notify my Consultant.

4. I understand that there is a legitimate interest in CWP and my Consultant holding the data on the Personal Records Form in conjunction with my use of the programme. I understand it may be necessary for you to provide data to medical professionals and vice versa in relation to me starting the Programme and that this is a vital interest which forms the legitimate basis for processing.

5. I am aware that it is my responsibility as a client to have regular medical reviews with my GP to assess any medication adjustments.

6. I have been supplied with the relevant CWP booklet and CWP privacy notice by my Consultant and I have read and understood these prior to complete this form.
Client agreement*

I agree with the above statementsI consent to my Consultant contacting me at any point regarding my weight loss journey, promotions and any business opportunities. If I wish to withdraw my consent at any stage I can do so by sending an email to my Consultant.I have read and answered the medical section of the form.
Signed

Clear
Date

MonthDayYear
Date
How did you hear about us?

Previous userTV advertsFrom a friendOther
How did you hear about Maria Collins?

From a friendGoogle/search engineThe 1:1 websiteOther
Support is a vital part of The 1:1 Diet. As well as 1:1 contact, we offer motivaional groups via whats app and facebook. Please tell us how much support you would like

I need all the motivation and support I can getI am happy with regular contact, but wish to keep it minimalI am a lone wolf and don't need any supportOther
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Personal Record Form

1. Contact Details

2. Personal Details

3. Medical Information

4. Client Deceleration