Client First Assessment Form - One2One Diet with Debbie Nolan

Your Full Name*

First NameLast Name

Your mobile phone Number*

Enter Your Phone Number

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*

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 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*

Do you have any of these conditions?*

Requires MEF

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

Step 4 minimum monitoring letter

Fertility medication

Step 3 minimum

smoking cessation medication (such as Champix)Stomach ulcerKidney stones

Step 1B minimum

Step 1b minimum and monitoring letter

Any step and monitoring letter

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

Do you have any other medical conditions?*

YesNo

What are the medical conditions:

None of options above apply

None of the options above

Do you take any Medications?*

YesNo

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?*

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.

Signature*

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

The 1:1 Diet by Cambridge Weight Plan with Debbie Nolan