The 1:1 Diet by Cambridge Weight Plan with Jolanta
First Assessment - Online Form. Please fill all the details required. Thank You!
Full Name
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First Name
Last Name
Phone Number
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Enter Your Phone Number
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E-mail
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Date of birth
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Preferred Way of communication
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Phone Call
WatsApp
Email
Address
Street Address
Street Address Line 2
City
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Postal / Zip Code
Typical weekly activity /exercise
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Your Weight
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Your Height
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Your Waist:
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Measuring your waist is a good way to check you're not carrying too much fat around your stomach, which can raise your risk of heart disease, type 2 diabetes, cancer and stroke
Your Occupation
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Do you Have any of these conditions?
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Alcoholic/substance misuser within one year of recovery
Anti-obesity medication
Serious illness, trauma or surgery(within the last three months
Serious mental health episode; such as schizophrenia, delusional disorder,psychotic episode, bi-polar disorder(within the last six months)
Current active anorexia, bulimia, or currently undergoing treatment for any eating disorder
Heart failure/attack, arrhythmia,valve disease requiring treatment(within the last three months)
MAOI medication
Stroke or TIA (within the last three months)
Pregnant, breastfeeding or given birth in the last three months
Yes (please specified from the list above)
No, I don't have any of them
Do you have any other medical conditions?
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No
Details - Medical Conditions
If you have answered yes, please write all medical conditions.
Do you take any Medications?
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No
Details - Medications -dosages and frequency:
If you have answered yes, please write all medications or pills you are taking.
Do you have any allergies or intolerances?
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Yes
No
Details - Allergies or Intolerances:
If you have answered yes, please give more details.
How did you hear about me?
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One2One Diet Webpage
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