Client Screening Form

New & Returning Client Screening Form

Thank you so much for your interest in starting your weight loss journey with me. Your answers will remain completely confidential, and are solely used to determine which step of the plan will suit you best.
A little bit about you

Please answer the questions truthfully, so I can best help you reach your goals.
Full Name*

First NameLast Name
Preferred Name
Email*
Please ensure your email address is completely accurate, as it will be used to create your unique code to use the 1:1 app. By providing your email address you are consenting to being contacted by me in accordance with General Data Protection Regulation Guidelines (GDPR).
Phone Number*

Area CodePhone Number
Address*

Street Address

Area

Town / CityCounty

Post Code
Date of Birth*
Gender at Birth*
Please note that this information is only required because we have to make sure you're put on the correct step for your physiological body type.
GP Surgery Name & Location*
Our protocol requires us to send a standard letter to the GP for some clients (dependent on various medical criteria). It is very unusual to hear anything in response, but it means the GP is aware they need to contact you for a medication (or other) review if you lose a significant amount of weight.
Lifestyle & Medical

These questions will hep me recommend which plan is best for your weight loss journey.
Your Height*
Your Weight (Nearest Stone estimate is fine if you're not sure)*
Your waist measurement*
Your Occupation*
Sedentary (eg. Sitting most of the day, very little movement/mobility)Moderately Active (eg. On your feet a lot, gentle exercise)Very Active (eg. Constantly on the go, lots of regular exercise)
YesNo
If yes, please provide details:
YesNo
If yes, please provide the medication name, dosage, frequency and what you take it for:
YesNo
If yes, please provide details:
YesNo
If yes, please provide details:
YesNoNot Applicable
YesNoNot Applicable
PLEASE NOTE: The 1:1 Diet by CWP is not suitable for those who are alcohol or substance dependent, underweight, pregnant, breastfeeding (as the sole source of their child's nutrition), have given birth within the past 3 months, or are under 14 years of age.

Unfortunately, if (or while) you fall into any of these categories, I will be unable to support your weight loss journey. I would recommend speaking to your GP about your wish to lose weight, and they should be able to recommend an appropriate way for you to do this.
Every client has their own unique reason for wanting to lose weight. It can be medical, occupational, social, personal, or something else altogether.

Please give me an idea of your goal weight and your unique motivation to lose weight, so I can help support you along your way.
What is your goal weight?*
What is your 'Why'? Maximum 50 words (so I can easily remind you of it when you need a boost!)

0/50
Is there any other information you think I should know before your first appointment?
You will receive a hard copy of our official Steps Booklet with your first product order.

You will also be able to view the full booklet through our app, which you will be able to access when I have processed your reponses to this form.

If you would like to view the full booklet before proceeding with this form, please use this link:

The 1:1 Diet by CWP Steps Booklet
Client Declaration

Please confirm the following and tick the box to agree with 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 by 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 Record 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 completing this form.
I agree with the above statementsI consent to my Consultant contacting me at any point regarding my weight loss journey, promotions and any business opportunity. If I wish to withdraw my consent for any of these at any stage, I can do so by sending a message to my Consultant.
My webpage on The 1:1 Diet websiteSocial MediaReferred by a friendPrevious clientNational Marketing Campaign (TV, radio, magazine etc.)Consultant Marketing
Thank you for taking the time to answer these questions. I will receive an email with all your answers once you submit this form, and I will contact you as soon as possible to discuss what I can do to support your weight loss journey.
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New & Returning Client Screening Form

A little bit about you

Lifestyle & Medical