The 1:1 Diet by Cambridge Weight Plan. Sarah Jane
First Assessment - Online Form. Please fill all the details required. Thank You!
Full Name
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First Name
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Interested In
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Your Approximate Weight
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Your Height
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Your Occupation
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Do you Have any of these conditions?
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Alcoholic/substance misuser within one year of recovery
Anti-obesity medication
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)
Current active anorexia, bulimia, or currently undergoing treatment for any eating disorder
Heart failure/attack, arrhythmia,valve disease requiring treatment(within the last three months)
MAOI medication
Stroke or TIA (within the last three months)
Pregnant, breastfeeding or given birth in the last three months
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No, I don't have any of them
Do you have any other medical conditions?
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Details - Medical Conditions
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Do you take any Medications?
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Details - Medications -dosages and frequency:
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Do you have any allergies or intolerances?
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I declare that the information given is correct. I consent to my Consultant contacting me at any point regarding my weight loss journey.
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