Help with Letter of Recommendation/Diet History

Can anyone help me with this? My PCP has asked that i compose the diet history and he will add i guess for the recommendation part. My question is do any one has a example of how their diet history looked. i just want to have everything in order when it's time to submit to the insurance company. Thanks, Jackie

Jackie: Here is an example of the letter or documentation. The required diet history below is provided for your information and utilization. I'm looking forward to being approved and having this surgery. I understand and accept the restrictionis I will have to follow for the rest of my life; but I know that it will give me some quality of life back and thats all I'm asking for is to be able to walk, run & play with my family; hopefully discontinue some medications I have to take daily as well as a healthier life style. This surgery is my only hope, I have tried diets in the past and always gain the weight back & then some. If you require further information, please do not hesitate to contact me. Sincerely, Jackie Year Type of Diet Weight Loss Time 2000 Kaiser Wt Loss Program 10lbs 3 mths 1995 Weigh****chers 50lbs 6 mts 1992 Physician Heart Diet 20lbs 5 mts 1989 Quick Weight Loss 20lbs 5 mts 1979 Weigh****chers 50lbs 6 mths This is something I think I used with my insurance company. Check with your doctor first to make sure the example is a good one. Use the wording. Hope this helps. Karen