• * Required fields

• Personal Details

• First Name: *
  
  Please enter first name
• Last Name: *
  
  Please enter last name
• Address: *
  
  Please enter an address
• City: *
  
  Please enter city
• Post Code:
• Home Phone: *
  
  Please enter phone number
• Work Phone:
• Fax:
• Email: *
  
  Please enter email
  
  Invalid email entered
• Gender: * Male Female
  
  Please select a gender
• Date of Birth: * Day 1 2 3 4 5 6 7 8 9 10 11 12 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January Febuary March April May June July August September October November December Year 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
  
  Please enter select date of birth
• Family Status:
• Number of Children:
• Occupation:
• Current Weight: (kg)
• Height: (cm)
• Desired Weight: (kg)

Medical History

• High or Low Blood Pressure: Yes No
• Any Heart Complaint: Yes No
• High Cholesterol: Yes No
• Asthma / Allergies: Yes No
• Fatigue / Anaemia / Energy Dips: Yes No
• Stress / Food Cravings / Depression: Yes No
• Poor Sleep: Yes No
• Headaches: Yes No
• Indigestion / Reflux: Yes No
• Ulcers: Yes No
• Urinary Tract Infection / Fluid Retention: Yes No
• Constipation, Bowel Problems: Yes No
• Regular Bowel Movements: Yes No
• Flatulence: Yes No
• Diabetes 2: Yes No
• Reaction after Missing Lunch: Yes No
• Epilepsy: Yes No
• Skin (Eczema / Psoriasis / Dermatitis): Yes No
• Thyroid High / Low: Yes No
• Pregnant or Breastfeeding: Yes No
• PMT or Menopause Symptoms: Yes No
• Are you on HRT / Contraception?: Yes No
• Do you smoke?: Yes No
• Are you taking any pain killers, diuretics?: Yes No
• If you have ticked any of the conditions above please explain
  eg. Eczema caused by dairy is not controlled,
  poor sleep have trouble getting off to sleep:
  
• Are you taking any sedatives, laxatives, sleeping pills?: Yes No
• Are you taking any other medications or supplements?: Yes No
• If yes, please list medications or supplements:
• Any other health problems?:

Activity/Exercise

• Your activity level: (Inactive)1 2 3 4 5 (Athlete)
• Please describe the activity and duration:

Present Eating Habits

• Breakfast
  What and how much do you eat?:
  
• Mid Morning
  What and how much do you eat?:
  
• Lunch
  What and how much do you eat?:
  
• Mid Afternoon / Pre dinner nibbles
  What and how much do you eat?:
  
• Dinner
  What and how much do you eat?:
  
• Snacks / Dessert
  What and how much do you eat?:
  
• Coffee / Soft drinks / Alcohol / Juice
  What and how much do you drink?:
  
• Water
  How much water do you drink each day?:
  
• Dining Out / Takeaways
  What type and how often?:
  
• Do you have any particulars likes or
  dislikes around food?
  
• Briefly detail what caused you to be overweight,
  including details of your previous weight loss
  programmes.
  
• Why do you want to lose weight?
  Do you have a special event or date?
  
• I believe that the information I have given is true to the best of my knowledge.
  
• I'm happy to receive promotional newsletters from system:slim.
• Yes, I would like to receive email reminders to re-order products
• I have read and understood the health disclaimer *
  
  Please read and accept the Health Disclaimer
• 
  Errors have occurred, please check all required fields have been completed.