New Enquiry Form for The 1:1 Diet by CWP with Elaine Myers

A little bit about you

Please answer the questions so that I can best help you to achieve your goals
1:1 Diet with Elaine Myers New Enquiry Form
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

DayMonthYear
Date
What's your why? This is not just about losing weight and feeling healthier, fitting smaller clothes - drill down and discover why you want to lose some weight and share this with me ...
Lifestyle and Medical

These answers help me to recommend the best plan for your journey
Please enter your Height
Please enter your approximate Weight
Please enter your approximate Measurements - Bust/Chest, Waist at Tummy Button and Hips
Do you have any Allergies/Intolerances or Dietary requirements
Your Occupation
Please indicate your level of Activity
Do you take any prescribed medication at all? If so, please give names, dosage and start date
Do you have any ongoing medical conditions? If so, please give full details
Have you had any general accidents or any surgery in the last 3 months?
Women only: have you given birth in the last 3 months?
Women only: are you currently breastfeeding?
NOTE: The 1:1 Diet is NOT suitable for any of the the following conditions: Alcohol/ substance misuser within 1 year of recovery. Current eating disorders. Heart failure/ attack/arrhythmia or valve disease requiring treatment in the last 3 months. MAOI medication taker. Serious mental health disorders such as schizophrenia, delusional disorder, psychotic episode, bipolar disorder within the last 6 months. Serious illness trauma or surgery within the last 3 months. Stroke / TIA within the last 3 months. Anti obesity medication. Ladies who are pregnant, breastfeeding, or who have given birth in the last 3 months, and those younger than 14 years.
Please let me know if you are mobile and able to travel to me at M45 7QA - or if you are looking for a consultant who will come to your own home or prefer a virtual consultation.
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Use this space to note anything else you think I should know or if you have any questions ahead of our chat eg how much weight you are looking to lose, timescales if any
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A little bit about you

1:1 Diet with Elaine Myers New Enquiry Form

Lifestyle and Medical