<p>Weekly Clinic Visit Questionnaire</p><p>Name: Date: ____/____/____ Phase: ______Week: </p><p>1. Did you have any symptoms or physical problems since your last visit? Yes ____ No ____</p><p>If Yes, circle and comment: Light-headedness Headache Cramps Shortness of Breath Shortness of Breath</p><p>Fatigue/Weakness Hair Loss Constipation Bruising/Bleeding</p><p>Nausea/Vomiting Diarrhea Other Comments: </p><p>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)</p><p>4. Current dietary plan? ______</p><p> a. Did you have problems adhering to the plan? Yes ____ No ____ Comment </p><p> b. Are you consuming a meal replacement formula? Yes ____ No ____ What Formula? ______How many packets each day? Mon ___ Tues ___ Weds ___ Thurs ___ Fri ___ Sat ___ Sun ___</p><p>Are you consuming Nutritional Bars? Yes ____ No ____</p><p>How many each day? Mon ___ Tues ___ Weds ___ Thurs ___ Fri ___ Sat ___ Sun ___</p><p>Did you drink at least 2 additional quarts of Yes ____ No ____ non-caloric fluid each day? </p><p> e. How many calories of food did you consume? Mon ___ Tues ___ Weds ___ Thurs ___ Fri ___ Sat ___ Sun ___ (other than formula or nutritional bars) </p><p>7. Did you exercise? Yes ____No ____ If Yes, how many days? ______Total number of minutes ______</p><p>Patient Signature </p><p>MEDICAL PROGRESS NOTES Weight ______Weight Change ______</p><p>Nurse: B/P Sitting ______/Standing ______</p><p>Pulse ______Lab Review Date ___/___/___</p><p>By ______</p><p>Signature: ______</p><p>Physician:</p><p>Signature Group Facilitator</p><p>Follow-up contact: Call / Letter ______Signature </p><p>107.077.797</p>