New Enquiry Form for The 1:1 Diet with Shelley

New Enquiry Form

one2onedietdroitwich@gmail.com
A little bit about you

Please answer the questions below ahead of our first meeting, this will help me establish which Step you can start plan on to best achieve your goals.
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Post Code
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
What's your why? This is not just about losing weight and feeling healthier, fitting into smaller clothes etc, drill down and discover why you want to lose some weight and share this me ......Holiday, special birthday etc
Lifestyle and Medical

These answers help me to recommend the best Step to start you on and plan your weight loss journey with the 1:1 Diet at Cambridge Weight Plan
Please enter your Height, in feet and inches
Please enter your approximate Weight, in stone and pounds
Please enter your approximate waist measurement, in inches
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 explain why you have to take this medication. ie Ramipril - 10mg daily - for hypertension
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 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, and those younger than 14 years.
Appointments and weigh in's will be held virtually via What's App or Facetime. Products can be collect from me locally (Droitwich only) or posted (1 month's worth of product min order) Is this acceptable to you?
How did you hear about me?
Space expands so type away!
Should be Empty:

New Enquiry Form

A little bit about you

Lifestyle and Medical