New Dieter Online Registration Form

New Dieter Online Registration Form

The 1:1 Diet - Coached By Natalie
Full Name*

First NameLast Name
Email Address*
example@example.com
Contact Number*

+44Phone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your gender?*
Date of birth:*

DayMonthYear
Date
What is your age?*
Lifestyle & Medical

Please fill in the information below
What is your typical weekly activity/exercise:*

SedentaryModerateVery Active
Please enter your Height?*
Please enter your Weight: (St / Kg)*
What is your Occupation?*
Do you have any of the following conditions?*

Alcoholic/substance misuser within one year of recoveryAnti-obesity medicationSerious illness, trauma or surgery (within the last three months)Serious mental episode, such as Schizophrenia, delusional disorder, psychotic episode, bi-polar disorder (within the last 6 months)Current active anorexia, bulimia, or currently undergoing treatment for any eating disorderHeart failure/attack, arrhythmia, valve disease requiring treatment (within the last three months)MAOI medication,Stroke or TIA (within in the last three months)Pregnant, breast feeding or given birth in the last three monthsDiabetes Type 1Diabetes Type 2 (controlled by more than Metformin)Diabetes Type 2 (controlled by diet or metformin and/or sitagliptin)Gastric surgical procedures (within one year)Fertility medicationStomach ulcerKidney stonesCancer in remissionEpilepsyKidney disease/failureLiver disease/failureProphyriaMental health disorders (stable)Angina/Arrythmia (stable)Diabetes InsipidusGoutPsoriasisRheumatoid arthritis treated with medicationAnti-coagulant medication (such as warfarin)Neuro/muscular conditions (such as MS, Fibromyalgia)Spinal conditions (such as Sciatica, spondylitis, scoliosis) treated with medicationAnaemiaAntibiotic medicationConstipationCrohn's disease, ulcererative colitis, IBSDiverticular diseaseGall stonesPain relief (moderate to strong)VertigoCholesterol medicationDiuretics (water tablets)Hypertension (high blood pressure)Thyroid medicationNone aboveOther
Are you currently taking any medication?*

YesNo
Please list them below:
Do you have any allergies or intolerances?*

YesNo
Please list them below:
How often do you consume alcohol?*

DailyWeeklyMonthlyOccasionallyNever
What are your motivations and goals for wanting to lose weight?*
Have you been on The 1:1 Diet by Cambridge before?*

YesNo
How did you hear about me?*
Are you interested in becoming be a 1:1 Diet Consultant?
Client Declaration

Please read and confirm the following below and sign in the box to agree with the declaration:

1. The information given is correct and I have been advised to consult my GP before starting any weight loss programme.

2. I understand the importance of following the selected Step according to directions given by my Consultant and additional literature supplied by CWP.

3. If my health status/medication changes while using any CWP Step, I agree to notify my Consultant.

4. I understand that there is a legitimate interest in CWP and my Consultant holding the data on the Personal Record Form in conjunction with my use of the Programme. I understand it may be necessary for you to provide data to medical professionals and vice versa in relation to me starting the Programme and that this is a vital interest which forms the legitimate basis for processing.

5. I am aware that it is my responsibility as a client to have regular medical reviews with my GP to assess any medication adjustments.

6. You will be supplied with the relevant CWP booklet and CWP privacy notice by my Consultant and I have read and understood these prior to completing this form.

Client agreement

I agree with the above statements*
Signature*

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New Dieter Online Registration Form

Lifestyle & Medical