Are you ready for change

A Wee Bit About You Form

Lorraine Bell with The 1:1 Diet by Cambridge Weight Plan
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

Town / CityState / Province

Post Code
Email*
Mobile*
Age*
Date of birth*

DayMonthYear
Occupation*
Activity Level*
Medical section

This is just to give us an idea of any possible medical conditions and medications to help us advise you on the most suitable plan for you.
Alcoholic/Substance misuse (within 1 year of recovery)Anti-obesity medicationHeart failure/attack, arrhythmia, valve disease requiring treatment (within last 3 months)MAOI medication (Monoamine Oxidase Inhibitors)Pregnant, breastfeeding or given birth in the last 3 monthsSerious illness, trauma or surgery (within last 3 months)Serious mental health episode such as schizophrenia, delusional disorder, psychotic episode, bipolar disorder (within last 6 months)Current active anorexia, bulimia or currently undergoing treatment for any eating disorderStroke or TIA (within last 3 months)
Approx Height*
Approx Weight*
Waist Measurement in inches*
Measure around the belly button
Please list any medical conditions you have. (If not applicable type N/A)*
Please list medications prescribed and dosages. (If not applicable type N/A)*
Allergies & Intolerance
What is your protein preference?
I give new clients a free bag of our tasty Pop Square crisps, which flavour would you prefer?
How did you find out about me?
Tell me the name of your friend and if they're on plan with me I'll give them a reward!
Pop a wee tick here if you're human*
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A Wee Bit About You Form

Medical section