Medical Screening Form

Before ordering any of our products you should complete the following medical screening form. This allows us to identify any potential medical conditions that may mean that our products are not suitable for you at this time.

    Your Name (required)

    Address Line 1 (required)

    Town / City (required)

    Postcode (required)

    Your Age (required)

    Contact Phone No. (required)

    Your Email (required)

    Medical Conditions

    If the answer to any of the following questions is 'Yes' then the My Diet Loss plan is not suitable for you as a method of weight loss.

    • Are you under the age of 16 or over the age of 80?
    • Is your current BMI 19 or under?
    • Are you pregnant, breastfeeding or have you given birth in the last 3 months?
    • Have you had any major surgery or trauma in the last 2 months?
    • Have you had any form of bariatric surgery?
    • Do you suffer from a serious kidney or liver disorder?
    • Do you suffer from or have previously suffered from a severe eating disorder?
    • Do you suffer from severe depression, psychosis, schizophrenia?
    • Do you have Type 1 diabetese or take insulin?



    If you answer yes to any of the following medication questions we may inform your GP that you have taken steps to lose weight with My Diet Loss. This will allow your GP to adjust your medication. On occasions we may consult with your GP and we may also send copies of the information provided within this form along with details of your My Diet Loss plan.

    Yes Are you taking any anti-hypertensives (for high blood pressure)?

    Yes Are you taking Duiretics (water tablets)?

    Yes Are you taking Anti-Consultants (for epilepsy)?

    Yes Tablets for diabetes (Type 2)?

    Your GP's Full Name (required)

    The GP Surgery Address (required)

    Surgery Postcode (required)

    We would recommend that you consult your GP before embarking on any weight loss programme.

    I have read the information above and agree to the terms and conditions and that the information I have given is true and accurate. i understand that if i have any of the medical conditions contained in part one of the medical screening form, any of the My Diet Plans are not suitable. I understand the importance of following the recommended plan and directions given by My Diet Loss. If my health changes I agree to notify my GP and My Diet Loss. I agree that My Diet Loss may at its discretion, refuse to supply me with any of their products if I provide misleading or incomplete information.

    Yes I confirm I have read the above and agree that the information I have submitted is accurate to the best of my knowledge.

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