The 1:1 Diet by Cambridge Weight Plan with Princess Caz
First Assessment - Online Form. Please fill all the details required. Thank You!
Full Name
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First Name
Last Name
Full Address & Postcode
Your residence
Mobile Number
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+44
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E-mail
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example@example.com
Your Occupation
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**
Preferred way of communication
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Weekly Activity
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Sedentary, Moderately Active or Very Active
DOB
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**
Your Weight (approx)
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Your Height (approx)
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Do you Have any of these conditions?
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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
Yes (please specified from the list above)
No, I don't have any of them
Do you have any other medical conditions?
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Yes
No
Details - medical conditions
If you have answered yes, please write all medical conditions.
Do you take any medications?
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No
Details - medication dosage and frequency:
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Do you have any allergies or intolerances?
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No
Details of allergies or/& intolerances:
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Other relevant information you feel you wish to share
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How did you hear about me
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Signature
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I declare that the information given is correct. I consent to my Consultant contacting me at any point regarding my weight loss journey.
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