New Client Enquiry Form

New Client Enquiry Form

The 1:1 Diet with Chelsie
Tell me about yourself…

Please answer the questions below ahead of our first meeting so that I can understand how to best support you with achieving your goals.
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

DayMonthYear
Date
What's your why? This helps me understand what is motivating you to loose weight
Lifestyle and Medical

These answers help me to recommend the best step to start on and plan your weight loss journey with The 1:1 Diet
Please enter your Height
Please enter your approximate Weight
Please enter your approximate Measurements - Bust/Chest, Waist at Tummy Button and Hips
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 start date
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.
Use this space to note anything else you think I should know or if you have any questions ahead of our chat ...
Space expands so type away!
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New Client Enquiry Form

Tell me about yourself…

Lifestyle and Medical