The 1:1 Diet Personal Record Form
Name
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Address
*
Street Address
Street Address Line 2
City
Postcode
Date of Birth
*
-
Day
-
Month
Year
Date
Gender
*
Occupation
Typical Weekly Activity
*
Sedentary
Moderate
Active
Height
*
Weight
*
Have you done the plan before
*
Yes
No
Please select any medical issues. If you have none please select none apply
*
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
Diabetes Type 1
Diabetes Type 2 (controlled by more than Metformin)
Gastric surgical procedures (within one year)
Kidney disease/failure
Liver disease/failure
Mental health disorders (stable)
Angina/Arrythmia (stable)
Gout
Anti-coagulant medication (such as warfarin)
Cholesterol medication
Diabetes Type 2 (controlled by diet or metformin and/or sitagliptin)
Diuretics (Water tablets)
Hypertension (high blood pressure)
Thyroid medication
Fertility medication
Smoking cessation medication (such as Champix)
Stomach ulcer
Kidney stones
Cancer in remission
Epilepsy
Porphyria
Diabetes Insipidus
Psoriasis
Rheumatoid arthritis treated with medication
Spinal conditions (Such as Sciatica, spondylitisis, scoliosis) treated with medication
Neuro/muscular conditions (such as MS, Fibromyalgia)
Anaemia
Antibiotic medication
Constipation
Crohn’s disease, ulcerative colitis, IBS
Diverticular disease
Gall stones
Pain relief (moderate to strong)
Vertigo
None Apply
Please list any other medical conditions, medications, allergies and intolerances here:
Signature
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Previous Client
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*
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