Client First Assessment Form - One2One Diet with LHB

The 1:1 Diet by Cambridge Weight Plan with LHB

Please answer the below questions to the best of your knowledge. This will enable me to learn more about you, your medical history and your goals. For existing clients I will use this information to update your medical record. All information provided is held confidentially and will allow me to plan which step is suitable for you to begin your weight loss journey!
Your Full Name

First NameLast Name
Your mobile phone Number

Area CodePhone Number
Your E-mail
example@example.com
D.O.B

DayMonthYear
Preferred way of communication
Address

Number and Street Address

Street Address Line 2

City

Postal Code
Occupation
Typical weekly activity /exercise
Please complete the following medical questions.

Please tick any conditions you are aware of, Any you are unsure of we can discuss in your consulation.

You will have the opportunity to list any medication your are taking as well as what it is used for further in the questionairre.

Please provide as much detail as possible.
Your Weight
Your Height
Your Waist: (if known)
Measuring your waist is a good way to check you're not carrying too much fat around your stomach, which raises the risk of heart disease, type 2 diabetes, cancer and strokes.
Your target weight
Do you have any of these conditions?
Requires MEF
Step 4 minimum monitoring letter
Step 3 minimum
Step 1B minimum
Step 1b minimum and monitoring letter
Any step and monitoring letter
Do you have any other medical conditions?
What are the medical conditions:
None of options above apply
Do you take any Medication?
Details - Dosages and frequency:
If you have answered yes, please write all medications or pills you are taking.
Do you have any allergies or intolerances?
Details - Allergies or Intolerances:
If you have answered yes, please give more details.
How did you hear about me?
Other
Please leave any other information that you would like to share.
Signature

I declare that the information given is correct. I consent to my Consultant contacting me at any point regarding my weight loss journey.
Should be Empty:

The 1:1 Diet by Cambridge Weight Plan with LHB