Medical Questionaire

• Your first purchase requires agreement to our Medical Information.  Read carefully and Check box if confirming
  

Section 1 - To be able to use the KeeDiet weight loss plans you must agree to the statements below in Section 1.  If you can not confirm the statements in Section 1 you are contraindicated and should not follow or use any KeeDiet weight loss plan. 

• I confirm that I am not pregnant, breast-feeding, given birth, miscarried or had an operation or serious accident within the previous 12 weeks.
• I confirm that I do not take MAOI (Monoamine oxidase inhibitors)
• I confirm that I do not take take anti-obesity medication
• I confirm that my BMI is not below 20
• I confirm that I am 18yrs +
• I confirm that I am not a substance misuser or dependant on alcohol
• I confirm that I do not have Type 1 Diabetes
• I confirm that I do not have and have never had heart failure or valve disease, a heart attack, angina or any serious heart condition;
• I confirm that I do not have and have never had Porphyria;
• I confirm that I do not have total lactose intolerance;
• I confirm that I do not have and have never had a severe psychiatric disorder, which includes major depressive disorder, psychotic episode, schizophrenia, bipolar disorder and delusional disorder;
• I confirm that I do not have and have never had liver disease or severe kidney disease;
• I confirm that I do not have or have never had any eating disorders, including anorexia and bulimia, nor am I having any treatment for any type of eating disorder;
• I confirm that I have never had a stroke or TIA ;
• I confirm that I am not taking any anti-coagulants for the treatment of thrombosis;

Section 2 - Medical Conditions & Medication - I understand that if any of the statements inSection 2 apply I may be eligble - with professional medical agreement and regular supervision only to use Kee Lifestyle Plans Etiq 3 or Etiq 4....

• I am prescribed and taking Anti-coagulants
• I am prescribed and taking Anti-convulsants for epilepsy
• I am prescribed and taking Arrhythmia medication
  
• I am a Male with a BMI 60+(1500kcal Lifestyle 4)
• I am a Male with a BMI 50-60 (1200kcal Lifestyle 3)
  
• I am a Female with a BMI 60+ (1200kcal Lifestyle 3)

Section 3  - Medical Conditions & Medication - I understand that if any of the statements in Section 3 apply I may be eligble - with professional medical agreement and regular supervision only - to use Kee New You Plan Etiq 2 and above....

• I have active gallstone which are managed
  
• I have Angina which is managed.
  
• I am a Male with a BMI 40-50
  
• I am a Female with a BMI 50-60
• I am prescribed and taking Morphine
• I am taking Champix (Anti Smoking)

Section 4  - Medical Conditions & Medication - I understand that if any of the statements in Section 4 apply I may be eligble - with professional medical agreement and regular supervision only - to use Kee Social Plan Etiq 1 and above...

• I have Anaemia , Crohns Disease, Diabetes Insipidus, Diverticulitis, Ulcerative Colitis, or Vertigo
  
• I have a history of Gallstones, Constipation, Kidney Stones
• I am prescribed and taking Infertility medication
• I am prescribed or taking moderate to strong pain relief
• I am prescribed or receiving Psoriasis tablets / injection
  
• I am a Female with a BMI 40-50

Section 5 - Special Precautions - I understand that if any of the statements in Section 5 apply I may be eligble to use the KeeDiet weight loss plans but must first seek professional medical agreement and follow weight loss with regular supervision only:

• Diet controlled Diabetes - Type 2 - Insulin Medication - Biguanides (Metformin or Glucophagel) - Other Diabetes medication.
  
• I am prescribed or taking Diruretics not associated with heart, liver or kidney disease
• I am currently suffering or have a history of Gout
• I am currently suffering or prescribed Hypertension medication
• I have a history of Gallstones, Constipation, Kidney Stones/Disease, Hypoglycaemia, Depression
• I am prescribed and taking Infertility medication
• I am prescribed or taking moderate to strong pain relief
• I am prescribed or receiving Psoriasis tablets / injection
• I am prescribed Cancer medication

• Caution is required for people suffering  Phenylketonuria (may need to avoid aspartame products ) , postural hypotension—(drink plenty and get up slowly from a sitting/lying position). Lactose intolerance and anyone attending a hospital within the last 12 months.

Section 6 - Clients Declaration

• I accept that by purchasing products to follow any KeeDiet weight loss plan, I have consulted my GP and received their consent and support so they can monitor my progress and organise changes to medication if necessary.
• I understand and accept that any advice or support provided by the KeeDiet via our webstore, email, telephone or litreature is NOT provided by medically trained person(s) and should therefore only be used as guidance, reference and confirmed with your GP or medically trained professional. 
  
• I understand that when following a very low calorie diet or a low calorie diet, I may experience minor temporary side effects. These could include any of the following: feeling cold, headaches, dizziness, gastro-intestinal disturbance, cramps, dry mouth, halitosis, fatigue and very occasionally, a greater risk of gallstones.
• I agree that whilst using any KeeDiet weight loss plan if I am concerned about my health, my health status/medication changes or I become unwell whilst following any KeeDiet weight loss plan I will inform my GP of the details of my Weight Loss Plan.
• I agree that if I am due to undergo any surgery or investigations or start a new course of treatment whilst following any KeeDiet Weight Loss Plan I will gain the agreement of GP before I continue on any KeeDiet Plan.
• I agree and understand that my health is solely my responsibility, I agree that whilst dieting it is advised and expected by The KeeDiet that I will have regular medical reviews with my GP to assess any medication and continued good health.
• I consent that Golo Carb UK Ltd  may hold my personal data and plan details for reference purposes only.
• I accept that Golo Carb UK Ltd may use  Google Adwords free conversion tracking tools
• I give "informed consent" that by using this webstore Golo Carb UK may record any detailed information in the cookies they store on visitors' computers
• I agree that I have read and understand the statements above.