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Online Questionnaire

Personal Information 
Last Name:  First Name:
TEL:
Mobile TEL:

Address:
 
 
Town / City
 
County
    POST:

email: 

 





  

    Height
    
    
  

  

    AGE
    
    
  

  

    D.O.B
Medical History
High Blood Pressure Chest Pains Glandular Fever
Gastric/Bowel Problem Hepitits Heart Complaint
Family Hist of Thyroid Asthma Indigestion
Diabetes Cancer Gout Epilepsy Kidney/Bladder
Liver/Gall Bladder Arthritis Cholesterol 
     

Do you have any Allergies?


Have you had HRT please give details?
Weight Gain ofter HRT?
How Long have you been overweight?
Cause of Problem?

Main Reason to Lose Weight?

Weight Loss Methods Tried Please detail any methods already tried detailing weight loss, how long ago and the reason stopped?
Current Medication If you are currently taking medication, please indicate it in the space below:
Eating Habits Please detail your typical daily eating habits
   
Breakfast Evening Meal
Mid Morning T.V Snacks
Lunch Snacks
Mid Afternoon Supper

Do you have a Worst time of the Day?

Dieting Problems

WEIGHT LOSS SUCCESS

Weight losses with The Natural Way diet programmes have been spectacular over the years – losses of five and six stones are not unusual.