The 1:1 Diet by Cambridge Weight Plan with Debbie Nolan
First Assessment - Online Form. Please fill all the details requested so we can plan your bespoke programme. You All information provided will be treated in the strictest confidence.
Your Full Name
Your mobile phone Number
Enter Your Phone Number
Preferred way of communication
Number and Street Address
Street Address Line 2
Typical weekly activity /exercise
Please complete the medical questions below.
Please tick any you are aware of. -
Any you are unsure of make a note and we can discuss in your consulation.
You will have the opportunity to list any medication your are taking and what it is used for further in the questionairre. -
Please provide as much detail as possible.
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
Do you have any of these conditions?
Alcoholic/substance misuser within one year of recovery
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)
Stroke or TIA (within the last three months)
Pregnant, breastfeeding or given birth in the last three months
Yes (please specified from the list above)
No, I don't have any of them
Diabetes Type 1
Diabetes Type 2 (controlled by more than Metformin)
Gastrical surgical procedures (within one year)
Step 4 minimum monitoring letter
Step 3 minimum
smoking cessation medication (such as Champix)
Step 1B minimum
Cancer in remission
Rheumatoid arthritis treated with medication
Spinal conditions (such as sciatica, spondylitisis, scoliosis) treated with medication
Neuro/muscular conditions (such as MS, fibromyaldia)
Crohn's disease, ulcerative colitis, IBS
Pain relief (moderate to strong)
Step 1b minimum and monitoring letter
Mental health disorders (stable)
Anit-coagulant medication (such as warfarin)
Any step and monitoring letter
Diabetes Type 2 (controlled by diet and meformin and/or sitagliptin)
Diuretics (Water tablets)
Hypertension (high blood pressure)
Do you have any other medical conditions?
What are the medical conditions:
None of options above apply
None of the options above
Do you take any Medications?
Details - Medications - dosages and frequency:
If you have answered yes, please write all medications or pills you are taking.
Do you have any allergies or intolerances?
Details - Allergies or Intolerances:
If you have answered yes, please give more details.
How did you hear about me?
One2One Diet Webpage
Other (Please specify...)
Please leave any other information that you would like to share.
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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