PHYSICIAN SUPERVISED WEIGHT-LOSS PROGRESS
Diet, Exercise and Behavior Modification
Patient Name: ________________________________________
Date of Birth: _________________________________________
Date of Visit:
________________________________________
S:
Patient is following a
|
q 800 kcal/day diet
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q 1500 kcal/day diet
|
q 1800 kcal/day diet
|
|
q 1200 kcal/day diet
|
q 1600 kcal/day diet
|
q 2000 kcal/day diet
|
|
q 1400 kcal/day diet
|
q 1700 kcal/day diet
|
q Other
|
Patient is participating in the following exercise regimen, as discussed:
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q Walking
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q Yoga
|
|
q Swimming
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q Aerobics
|
|
q Curves
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q Gym/Club membership
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q Patient unable to exercise due to __________________________________________________
q Other _______________________________________________________________________
O:
Vitals
Height: _____ Weight: _____ HR: _____ R: _____ BP: _____
A:
q Morbid Obesity
q Change in weight since last visit
Lost _____ lbs.
Gained _____ lbs.
q No change in weight since last visit
P:
Patient is to follow a
|
q 800 kcal/day diet
|
q 1500 kcal/day diet
|
q 1800 kcal/day diet
|
|
q 1200 kcal/day diet
|
q 1600 kcal/day diet
|
q 2000 kcal/day diet
|
|
q 1400 kcal/day diet
|
q 1700 kcal/day diet
|
q Other
|
q Patient is to continue exercise
q Return to office in one month to evaluate progress
q Patient counseled on the importance of behavior modification and lifestyle changes
Additional Comments: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________
Physician Signature