New Dieter Enquiry Form
You have been sent this form because you have shown interest in 1:1 With Gems, please complete and submit so I can get in touch with some more information!
Contact Details
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postcode
Phone Number
*
E-mail
*
Confirmation Email
example@example.com
When and how is best to contact you?
Personal Details
These answers, along with all of the information requested on this form, is to help me tailor your plan to suit you for your journey.
Date Of Birth
*
-
Day
-
Month
Year
Date
Gender
*
Please enter your height
*
or approximate (state if using cm, inches or feet)
Please enter your current weight
*
or approximate (state if using kg or st and lbs)
Your Occupation
*
Please indicate your level of activity
*
Please Select
Sedentary
Moderately Active
Very Active
Medical Information
If you are unsure or want to mention something not listed, please use the notes section below.
Do you have any of the following medical conditions? Tick all that apply
*
Alcoholic / Substance misuse 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)
MAOI medication
Mental health disorders (stable)
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)
Angina/Arrythmia (stable)
Hypertension (high blood pressure)
Stroke or TIA (within the last three months)
Cancer in remission
Porphyria
Epilepsy
Pregnant, breastfeeding or given birth in the last three months
Fertility medication
Diabetes Type 1
Diabetes Type 2 (controlled by more than Metformin)
Diabetes Type 2 (controlled by diet or metformin and/or sitagliptin)
Diabetes Insipidus
Gastric surgical procedures (within one year)
Smoking cessation medication (such as Champix)
Rheumatoid arthritis treated with medication
Spinal conditions (Such as Sciatica, spondylitisis, scoliosis) treated with medication
Neuro/muscular conditions (such as MS, Fibromyalgia)
Vertigo
Stomach ulcer
Gout
Kidney stones
Kidney disease/failure
Liver disease/failure
Gall stones
Anaemia
Psoriasis
Constipation
Crohn’s disease, ulcerative colitis, IBS
Anti-coagulant medication (such as warfarin)
Diverticular disease
Antibiotic medication
Cholesterol medication
Thyroid medication
Diuretics (Water tablets)
Pain relief (moderate to strong)
NONE APPLY
Other (please specify below)
Do you take any prescribed medication? If so please give names and dosage.
Do you have any allergies or intolerances? If so please specify or type none
*
What are your goals and motivations?
For example what are you looking to achieve?
Anything else I should know? Or any questions?
How did you hear about me?
Please Select
Friend/Family
Newspaper/Magazine
Social Media
TV
Other
Referred by someone you know, who?
Extra information
Should you wish to go on plan, you will need to agree to the following Client Declaration;
The information given is correct and I have been advised to consult my GP before starting any weight loss programme.
I understand the importance of following the selected Step according to directions given by my Consultant and additional literature supplied by CWP.
If my health status/medication changes while using any CWP Step, I agree to notify my Consultant.
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.
I am aware that it is my responsibility as a client to have regular medical reviews with my GP to assess any medication adjustments.
I have been 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.
View the steps booklet
here
and
Privacy Notice
I consent to my consultant contacting regarding my weight loss journey, promotions and any business opportunities. If I wish to withdraw consent I can do so at any time by contacting my consultant
*
Yes
No
I have read the privacy notice (required)
*
Thank you!
Please submit this form and I will be in touch to discuss this further!
Submit
Should be Empty: