Cambridge 1:1 Weight Plan

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityCounty

PostcodeCountry

Date Of Birth

Sex

Occupation

Contact Number

Area CodePhone Number

Email

example@example.com

Height

In Feet and Inches

Weight

In Stones and Pounds

Goal Weight

In Stones and Pounds

Doctor's Name and Address Details

Tick any of the following conditions that apply to you:

If you have ticked any of the above conditions, please provide further information below.

If you have any ongoing medical conditions or recent surgeries/medical interventions NOT listed above, please provide further information below.

Are you currently taking any of the following medications?

Are you currently taking any other medications NOT listed above?

If yes, please provide further information below.

Do you have any specific dietary requirements?

If yes, please provide further information below.

How often do you consume alcohol?

Would you describe your current activity levels as:

What is your reason/motivation for deciding to lose weight? Your "why" helps me understand what is motivating you to lose weight and make positive lifestyle changes.

Are you familiar with the 1:1 Diet by Cambridge Weight Plan?

Have you ever done the 1:1 Diet by Cambridge Weight Plan before (previously known as The Cambridge Diet)?

If yes, when did you last finish on plan? Why did you stop? How did you find your experience? Is there anything you would like to do differently this time?

This information helps me to support you in the best way possible

What is your preferred contact method for your Initial Consultation (the contact method can be changed at any time to suit your needs)

What is your preferred time for your Initial Consultation? All further consultations/weigh-ins can be booked directly via the 1:1 Diet App.

After your Initial Consultation, I will follow-up with you in one weeks time. After that, would you prefer your check-ins to take place:

I understand that I must drink at least 2.5 litres of water a day (not including tea/coffee/diet drinks etc) when following the 1:1 Diet. This is important in order to keep hydrated and can help to avoid experiencing any temporary side effects.

Temporary side effects may include coldness, constipation, diarrhoea, headache.

Please Note: The 1:1 Diet by Cambridge Weight Plan is NOT appropriate for those who are pregnant, breastfeeding (where it is the sole source of nutrition), have given birth/had a major trauma/had surgery within the last 3 months, current active eating disorder, serious mental health episode within the last 6 months, on MAOI medication, alcohol or substance misusers within one year of recovery, heart failure/attack / arrhythmia/valve disease / stroke/TIA within the last 3 months, those younger than 14 years of age, those with a BMI of 70+

I agree to be contacted via Text Message to confirm a Day and Time ahead of our Initial Consultation. All further appointments can be booked directly through the 1:1 Diet App.

I am happy to be added to the 1-to-1 Diet Ireland WhatsApp Broadcast group and receive 1:1 Diet-related messages and special offers specific to my clients only. Please note all replies in a "Broadcast" group are private and only seen by myself and the respondee. You are free to withdraw consent at any time.

Referral Name (if you were referred to me by someone) to ensure they get their referral bonus:

Please use the space below to note anything else you think I should know or if you have any questions ahead of our consultation. I look forward to talking to you soon 💛