Thank you for your enquiry. Please complete and return this form and I will be in touch with you very soon 🙏❤️
Please Note:
The 1:1 Diet is NOT suitable for any of 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 month. Stroke/ TIA within the last 3 months. Anti obesity medication.
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
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Date Of Birth
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Year
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Gender At Birth
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Lifestyle And Medical
These answers help me to recommend the best plan for your journey.
Please enter your Height
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Please enter your weight
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Your occupation
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Please indicate your level of activity
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Sedentary
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Do you have any ongoing medical conditions? If so, please give details
Do you take my prescribed medication? If so, please give names and dosage
Do you have any allergies or tolerances? If so please state
Have you had any general accidents or surgery in the last 3 months
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Women only: have you given birth in the last 3 months?
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Yes
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Women only: are you currently breastfeeding?
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Please let me know any additional information such as how much weight you are looking to lose, timescales if any, and if you would prefer face to face appointments or virtual with collection/delivery of products.
Do you have any of the following please;
Diabetes type 1
Diabetes type 2 controlled by more than metformin
Gastric surgical procedure (within one year)
Fertility medication
Smoking cessation medication (such as Champix)
Stomach ulcer
Kidney stones
Cancer in remission
Epilepsy
Kidney disease/ failure
Liver disease/ failure
Porphyria
Mental health disorders (stable)
Angina/Arrythmia (stable)
Diabetes insipidus
Gout
Psoriasis
Rheumatoid Arthritis treated with medication
Anti-coagulant medication (such as warfarin)
Neuro/Muscular conditions (such as MS/Fibromyalgia)
Spinal conditions (such as Sciatica, spondylitis, scoliosis) treated with medication
Anaemia
Antibiotic medication
Constipation
Crohn’s disease, Ulcerative colitis, IBS
Diverticular disease
Gall stones
Pain relief (moderate to strong)
Vertigo
Cholesterol medication
Diabetes type 2 (controlled by diet or metformin and/or Sitagliptin
Diuretics (water tablets)
Hypertension (high blood pressure)
Thyroid medication
None of the above conditions apply to me
Where did you hear about me (eg. Facebook/ Instagram/ 1:1 website?
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