New Enquiry Form

New Enquiry Form

The 1:1 diet with Phillippa
Get to know you

Please complete the form below before our consultation so that I can best help you achieve 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
Gender at birth*
Tell me your why and the reason for wanting to loss weight ? This helps me understand your reason. *
Lifestyle

These questions help me recommend the best Step to start you on with this plan.
Height*
Weight in Stone*
Measurements: Chest, Waist & Hips
Activity Level*
Occupation *
Medical
PLEASE NOTE: The 1:1 diet is not suitable for anyone that is alcohol dependent, substance users, underweight, pregnancy, breastfeeding, or who given birth in the last 3 months and those under 14 years old.
Do you have any allergies/Intolerances or Dietary requirements ?*
Do you have any of the following health conditions ?

Diabetes Type 1Diabetes Type 2 controlled by more than metforminGastric surgical procedure (within one year)Fertility medicationSmoking cessation medication (such as Champix)Stomach ulcerKidney stonesCancer in remissionEpilepsyKidney disease/FailureLiver disease/FailurePorphyriaMental health disorders (stable)Angina/ ArrythmiaDiabetes insipidusGoutPsoriasisRheumatoid Arthritis treated with medicationAnti-coagulant (such as warfarin)Neuro/Muscular conditions (such as MS/Fibromyalgia)Spinal conditions (such as Sciatica, spondylitis, scoliosis) treated with medicationAnaemiaAntibiotic medicationConstipationCrohn’s disease, Ulcerative colitis, IBSDiverticular diseaseGall stonesPain relief (moderate to strong)VertigoCholesterol medicationDiabetes Type 2 (controlled by diet or metformin and/or SitagliptinDiuretics (water tablets)Hypertension (high blood pressure)Thyroid medicationNone of the above conditions apply to me
Do you take any prescribed medication ? If so, please give name, dosage and start date. *
Do you have any ongoing medical conditions? If so, please give full details. *
Have you had any surgeries in the last 3 months?*
WOMEN ONLY: Have you give birth in the last 3 months ?*
WOMEN ONLY: Are you currently breastfeeding?*
Let’s Chat 📱

Please select a time and date that would be convenient for you for us to have a chat about your plan.
Please use this space to add any extra details you may think will help me.
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New Enquiry Form

Get to know you

Lifestyle

Medical

Let’s Chat 📱