Weekly Clinic Visit Questionnaire

Name: Date: ____/____/____ Phase: ______Week:

1. Did you have any symptoms or physical problems since your last visit? Yes ____ No ____

If Yes, circle and comment: Light-headedness Headache Cramps Shortness of Breath Shortness of Breath

Fatigue/Weakness Hair Loss Constipation Bruising/Bleeding

Nausea/Vomiting Diarrhea Other Comments:

2. Have you received any other medical care this week? Yes ____ No ____ If Yes, who: Reason: 3. Any medications taken this week? Yes ____ No ____ If Yes, what: (New medications, dosage changes, stopped a medication)

4. Current dietary plan? ______

a. Did you have problems adhering to the plan? Yes ____ No ____ Comment

b. Are you consuming a meal replacement formula? Yes ____ No ____ What Formula? ______How many packets each day? Mon ___ Tues ___ Weds ___ Thurs ___ Fri ___ Sat ___ Sun ___

Are you consuming Nutritional Bars? Yes ____ No ____

How many each day? Mon ___ Tues ___ Weds ___ Thurs ___ Fri ___ Sat ___ Sun ___

Did you drink at least 2 additional quarts of Yes ____ No ____ non-caloric fluid each day?

e. How many calories of food did you consume? Mon ___ Tues ___ Weds ___ Thurs ___ Fri ___ Sat ___ Sun ___ (other than formula or nutritional bars)

7. Did you exercise? Yes ____No ____ If Yes, how many days? ______Total number of minutes ______

Patient Signature

MEDICAL PROGRESS NOTES Weight ______Weight Change ______

Nurse: B/P Sitting ______/Standing ______

Pulse ______Lab Review Date ___/___/___

By ______

Signature: ______

Physician:

Signature Group Facilitator

Follow-up contact: Call / Letter ______Signature

107.077.797