With Ria & Simon
Thank you for your enquiry, please fill in the information below to enable me to set you up on the database and advise your correct starting step.
Personal Information
Please answer the questions so that I can best help you achieve your goals.
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Area Code
Phone Number
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
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Day
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Month
Year
Date
Lifestyle and Medical
These answers help me to recommend the best step for your weight loss journey.
Please Enter your Height
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Please enter your approximate Weight
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Your Occupation
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Please indicate your level of Activity
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Please Select
Sedentary
Moderately Active
Very Active
Do you take any prescribed medication at all? If so please give names and dosage.
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Do you have any medical conditions? If so, please give details
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Do you have any allergies or intolerances? If so, please give details
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Have you had any general accidents or any surgery in the last 3 months?
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If yes, please provide further details below including the date of the accident / surgery.
Women only: have you given birth in the last 3 months?
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Yes
No
Women only: Are you currently breastfeeding?
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No
NOTE: The 1:1 Diet by Cambridge Weight Plan is NOT appropriate for those who are alcoholic, substance misusers, underweight, pregnant, breastfeeding, or who have given birth in the last 3 months. The minimum age to start plan is 14 years of age?
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How did you find me? If recommended by someone, please provide their name.
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