nut in horseheads elmira

i am  seeing  dr moon in horse heads  went to the  group meating  and  the  nut  talked to every one  and   if i remember  coreectly  she  gave  us  a   form to fill out  all the diets weve  been one    i lost the paper  so i was wondering  if any one  else    remembers this  so i can go a head and just write it  down on  a piece of paper   just  need to no  what exactly she wanted

OK I already handed mine in but I think I can remember.  Type of diet                 Duration of Diet                    Weight  Lost.