Client First Assessment Form - Juno Weight Loss Transformation Clinic

Your Full Name*

First NameLast Name

Your mobile phone Number*

Enter Your Phone NumberFormat: 00000000000.

Your E-mail*

example@example.com

D.O.B*

Preferred way of communication

Address*

Number and Street Address

Street Address Line 2

City

Postal Code

Occupation*

Typical weekly activity /exercise*

Your Weight*

Your Height*

Your Waist: (if known)

Measuring your waist is a good way to check you're not carrying too much fat around your stomach, which can raise your risk of heart disease, type 2 diabetes, cancer and stroke.

Your target weight*

Diabetes Type 1Diabetes Type 2 (controlled by more than Metformin)Gastrical surgical procedures (within one year)

Fertility medication

smoking cessation medication (such as Champix)Stomach ulcerKidney stones

Chloresterol medicationDiabetes Type 2 (controlled by diet and meformin and/or sitagliptin)Diuretics (Water tablets)Hypertension (high blood pressure)Thyroid medication

YesNo

What are the medical conditions:

None of the options above

YesNo

Details - Medications - dosages and frequency:

If you have answered yes, please write all medications or pills you are taking.

YesNo

Details - Allergies or Intolerances:

If you have answered yes, please give more details.

How did you hear about me?*

Other

Please leave any other information that you would like to share.

I confirm that all information I have provided regarding my Medical history, current medications, allergies and intolerances, and any other relevant health conditions is complete, accurate and upto date to the best of my knowledge.

I understand that this information is essential for my wellbeing, safety and to ensure the appropriate diet plan is provided.

I acknowledge that the clinic and its practitioners cannot be held responsible for any adverse side-effects, complications, or health related outcomes that may arise as a result of inaccurate, incomplete or withheld information.

I accept full responsibility to ensure the clinic is kept fully update in the future.

I understand and agree that Juno Transformative Weight Loss clinic except no liability or responsibility for any individual that becomes a client the clinic. The responsibility and Liability lies solely with the individual client

I give full permission for the clinic to use any media images they hold of me within compliance of GDPR

Signature*

I declare that the information given is correct. I consent to the clinic contacting me at any point regarding my weight loss journey.

Juno Transformative Weight Loss Clinic based in Nottingham