1:1 Diet New Enquiry Form

1:1 Diet New Enquiry Form

with Debbie B
Contact Details
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Format: 00000 000 000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please advise the best day & time to contact you*
Personal Details

These answers together with your medical information will help me to recommend the best plan for your journey
Date of Birth*

DayMonthYear
Date
Gender*
Please Enter your Height*
Please state if using cm or feet & inches
Please enter your approximate Weight*
Please state if using kg or Stones and pounds
Please enter your waist measurement
Please state if using cm or inches
Your Occupation*
Please indicate your level of Activity*
Medical Information

If you are unsure of anything listed, please let me know in the notes section at the bottom
Alcoholic / Substance misuse within one year of recoveryAnti-obesity medication (not GLP-1)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 medicationMental health disorders (stable)Current active anorexia, bulimia, or currently undergoing treatment for any eating disorderHeart 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 remissionPorphyriaEpilepsyPregnant, breastfeeding or given birth in the last three monthsFertility medicationDiabetes Type 1Diabetes Type 2 (controlled by more than Metformin)Diabetes Type 2 (controlled by diet or metformin and/or sitagliptin)Diabetes InsipidusGastric surgical procedures (within one year)Smoking cessation medication (such as Champix)Rheumatoid arthritis treated with medicationSpinal conditions (Such as Sciatica, spondylitisis, scoliosis) treated with medicationNeuro/muscular conditions (such as MS, Fibromyalgia)VertigoStomach ulcerGoutKidney stonesKidney disease/failureLiver disease/failureGall stonesAnaemiaPsoriasisConstipationCrohn’s disease, ulcerative colitis, IBSAnti-coagulant medication (such as warfarin)Diverticular diseaseAntibiotic medicationCholesterol medicationThyroid medicationDiuretics (Water tablets)Pain relief (moderate to strong)NONE APPLY
Are you taking GLP 1 medication?
Do you take any prescribed medication at all? If so please give names and dosage.
Do you have any other medical conditions? If so, please give details
Do you have any allergies or intolerances? If so, please give details or type None*
What are your goals and Motivations?
Space expands so type away!
Use this space to note anything else you think I should know or if you have any questions ahead of your appointment.
Space expands so type away!
How did you find us?*
If referred by a friend, who?
Extra Information

Should you wish to start plan, you need to agree to the following Client Declatation during our first consultation:
1. The information given is correct and I have been advised to consult my GP before starting any weight loss programme.
2. I understand the importance of following the selected Step according to directions given by my Consultant and additional literature supplied by CWP.
3. If my health status/medication changes while using any CWP Step, I agree to notify my Consultant.
4. 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.
5. I am aware that it is my responsibility as a client to have regular medical reviews with my GP to assess any medication adjustments.
6. 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.
  
  The 1:1 Diet app is free for all clients, to log in you'll need the address you've suplplied above together with a unique dieter code that I can provide once you've agreed to the above statements.
  
  We can discuss this when we speak however,
  
  Looking forward to getting in touch,
  Debbie B
YesNo
To view a copy of our online Steps Book, please click here.
We have a Fantastic New app, available on Apple & Android.
- Track your weight
- Book Consultations
- View the Product catalogue
- Make order requests
- Features Helpful recipes when on Step 2 and above!
- Read amazing Success Stories
Download on Apple: Click here

Download on Android Play Store: Click here

You will need the email address you signed up with and your dieter code which I will supply.

Debbie B x
Should be Empty:

1:1 Diet New Enquiry Form

Contact Details

Personal Details

Medical Information

We have a Fantastic New app, available on Apple & Android.