Enquire About Support in the Dietetically Speaking Clinic
This form helps us understand your needs and determine how we can best support you. Please answer the questions as honestly and thoroughly as you feel comfortable. The details you include in this form will be handled securely in line with the GDPR and UK GDPR (and all enquiry data is automatically deleted after 90 days).
Full Name
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First Name
Last Name
E-mail
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example@example.com
Phone Number
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-
Area Code
Phone Number
Where did you hear about the Dietetically Speaking Clinic?
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Please tick this box if your enquiry is for somebody under the age of 18
What would you like support with? Please include your main struggles related to food or eating and describe the specific changes you would like to achieve.
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How ready do you feel to commit to working on this and why is now the right time?
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Do you have any medical diagnoses or conditions we should be aware of? (Examples include eating disorders, PCOS, IBS, food allergies, etc.)
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Have you ever engaged in the following disordered behaviours? [tick any that apply and add ‘other’ if needed)
Counting calories
Binge eating
Obsessive exercise
Vomiting after eating
Taking diet pills
Laxative misuse
Diuretic misuse
Other
When/how recently did you engage in the above behaviours?
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If you know your height and weight or BMI what are these? Has your weight significantly changed over the past 12 months?**
**Please note: we are a non-diet, weight-inclusive service so we only focus on these numbers for initial screening or specific health risks e.g. low weight eating disorder recovery.
Do you have a preference over which Dietitian(s) in our clinic you would like to work with?
Is there anything else you would like to share with us?
Add me to the Dietetically Speaking mailing list to receive updates and information about nutrition, relationship with food and services.
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