Form for those doing supervised diets
Hi everyone, I understand the frustration of the supervised diet. I had to do a 12 month one, after I had been on W.W. for 1.5 years, but I had no Dr. supervision of that diet, so I had to start from day one.
It is very important to go every single month to be weighed in by your Dr. and to see your progress, problems, and struggles. Although it seems like waiting any more time is to long, it really is worth it. I am 5 months out and I have lost 104lbs. I couldn't be happier!!!! Here is the form my Dr. used or if you would like I will email it to you. Just send me your email address, and I will reply. My email address is [email protected] Best of luck, Jen
PHYSICIAN SUPERVISED WEIGHT-LOSS PROGRESS NOTE
Diet, Exercise and Behavior Modification
Patient Name: ________________________________________
Date of Birth: _________________________________________
Date of Visit: _________________________________________
S:
Patient is following a
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q 800 kcal/day diet
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q 1500 kcal/day diet
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q 1800 kcal/day diet
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q 1200 kcal/day diet
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q 1600 kcal/day diet
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q 2000 kcal/day diet
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q 1400 kcal/day diet
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q 1700 kcal/day diet
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q Other
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Patient is participating in the following exercise regimen, as discussed:
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q Walking
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q Yoga
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q Swimming
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q Aerobics
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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
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q 800 kcal/day diet
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q 1500 kcal/day diet
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q 1800 kcal/day diet
|
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q 1200 kcal/day diet
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q 1600 kcal/day diet
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q 2000 kcal/day diet
|
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q 1400 kcal/day diet
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q 1700 kcal/day diet
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q Other
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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
Hockeymom87 · 0 replies · 635 views
