Register for a Home Support Programme

Name

Address

Postcode

Daytime tel.

Evening tel.

Current Weight

Current Clothes Size

Goal Weight

Goal Clothes Size

Time frame in which you hope to achieve weight loss

Is your lifestyle sedentary or active?

Do you suffer from any of the following:

Diabetes
Heart disease
High cholesterol
High blood pressure

Are you a vegetarian?

Do you exercise regularly?

What type of exercise do you do?

What day of the week would suit you for your home support Diet Secret consultant to call you?

What time frame would you prefer to be contacted on?