The Ph. Metabolic Edit Programme Intake Form

The Ph. Metabolic Edit Programme Intake Form

Please complete this form accurately to help us tailor your program safely and effectively. Have your health details ready.
Personal Details
Full name*

First NameMiddle NameLast Name
Date of birth*

DayMonthYear
Date
Mobile number*
Please enter a valid phone number.Format: 00000000000.
Email address*
example@example.com
Home address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred contact method*

Mobile phoneEmailText messagePostal mailOther
GP practice name*
GP practice address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
NHS number (if known)
Occupation
Programme Suitability / Basic Screening
Is this form being completed for yourself?*

YesNo
Height (cm)*
Current weight (kg)*
Waist circumference if known (cm)
Which of the following have you been told you have?

PrediabetesType 2 diabetesInsulin resistanceGestational diabetesPCOSMetabolic syndromeOther
When were you first told about these conditions?

MonthDayYear
Date
Have you ever used a continuous glucose monitor?*

YesNo
If yes, please briefly describe your experience or any notable results
Medical History
Medical conditions (tick all that apply)

High blood pressureRaised cholesterolCardiovascular diseaseKidney diseaseLiver diseaseFatty liverThyroid disorderAsthma/COPDSleep apnoeaAnxiety/depressionEating disorder historyPancreatitis historyGallbladder problemsGoutArthritisCancer historyAutoimmune diseaseOther long-term conditionNone of the above
Other medical conditions not already mentioned
Previous operations or hospital admissions relevant to health
Family history

DiabetesHeart diseaseStrokeObesityHigh cholesterolOther relevant family history
Medication History
Current prescribed medicines
Any recent medication changes in the last 6 months?*

YesNo
Please describe the medication changes
Are you currently or previously taking weight loss medications?*

YesNo
Please provide details of weight loss medications
Are you taking insulin or any diabetes tablets or injections?*

YesNo
Please list diabetes medicines and details
Vitamins, supplements, or over-the-counter medicines
Medication allergies or intolerances
Side effects or concerns with your current medicines
Medication adherence

1

2

3

4

5

6

7

8

9

10

1 is Rarely take as prescribed, 10 is Always take as prescribed
Bloods and Investigations History
Most recent HbA1c (%)
Date of most recent HbA1c

DayMonthYear
Date
Cholesterol results (if known)
Triglycerides (if known)
Liver blood tests / liver function results (if known)
Kidney function / eGFR (if known)
Blood pressure readings (if known)
Weight trend over the last 12 months
Previous CGM use or results, and any scans or investigations relevant to metabolic health
Would you be happy to upload or bring your results to the appointment?

YesNo
Symptoms and Current Concerns
Current symptoms*

FatigueBrain fogSugar cravingsIncreased thirstFrequent urinationPoor sleepLow moodBloatingRefluxHeadachesDizzinessBreathlessness on exertionSnoringJoint painLow energy after mealsOther symptoms
Biggest current health concerns*
What prompted you to join now?*
Lifestyle Intake
Usual weekday eating and drinking*
Usual weekend eating and drinking*
Alcohol intake
Smoking or vaping status*

NeverFormerCurrent - SmokerCurrent - VaperCurrent - BothPrefer not to say
Caffeine intake
Exercise or movement currently undertaken
Average daily steps (if known)
Sleep quality

1

2

3

4

5

6

7

8

9

10

1 is Very poor, 10 is Excellent
Usual sleep duration
Stress levels

1

2

3

4

5

6

7

8

9

10

1 is Very low, 10 is Very high
Who do you live with?
Who does the food shopping and cooking at home?
Do you work shifts?

YesNoSometimesPrefer not to say
Dietary preferences, restrictions, or cultural requirements
Goals and Motivation
What would success look like in 10 weeks?*
Top goal 1*
Top goal 2
Top goal 3
How motivated are you to make changes right now?*

1

2

3

4

5

6

7

8

9

10

1 is Not motivated, 10 is Extremely motivated
What has got in the way previously?
What support would help most?

Accountability check-insMeal planning guidanceExercise planEducation and adviceStress management supportFamily or social supportRegular progress reviewOther
Any additional support details
PT and Coaching Details
Open to working with the PT as part of the programme?*

YesNo
Injuries, mobility issues, back pain, joint pain, or other physical limitations
Exercises you enjoy or dislike
Confidence with home exercise

1

2

3

4

5

6

7

8

9

10

1 is Not confident, 10 is Very confident
Confidence with gym exercise

1

2

3

4

5

6

7

8

9

10

1 is Not confident, 10 is Very confident
Preferred days and times for PT or classes

Weekdays morningsWeekdays afternoonsWeekdays eveningsSaturdaySundayFlexibleOther
Preferred exercise format*

Home-based exerciseGym-based exerciseClassesWalking-focused supportMix of these
Pregnancy, breastfeeding, or trying to conceive*

NoYesUnsure
History of type 1 diabetes*

NoYesUnsure
Do any of the below apply?

Severe hyposDiabetic ketoacidosisEating disorderPancreatitisMedullary thyroid cancerMEN2Severe renal impairmentSevere liver diseaseRecent unexplained weight lossOther
Details of any urgent symptoms or concerns
Consent and Declaration
I confirm that the information provided is accurate to the best of my knowledge*

I confirm
I consent to being contacted about my programme*

I consent
I consent to clinical review of the health information I have provided*

I consent
I would like to receive follow-up educational emails or messages

I consent to follow-up communications
Signature*
Date*

MonthDayYear
Date
Should be Empty:

The Ph. Metabolic Edit Programme Intake Form

Personal Details

Programme Suitability / Basic Screening

Medical History

Medication History

Bloods and Investigations History

Symptoms and Current Concerns

Lifestyle Intake

Goals and Motivation

PT and Coaching Details

Consent and Declaration