PHYSICIAN PROGRESS NOTE FOR WEIGHT LOSS ATTEMPT
Patient: _____________________________________________________
Date: _______________________________________________________
Height: ________ Weight: _________
Diet:
Extremely low calorie (800 cal)_______ Very low calorie (1000-1200) _______
Low Calorie _______ Diabetic Diet _______ Weight Watchers _______
Low Fat Diet _______ Carbohydrate Free _______ South Beach _______
Protein Diet _______ Jenny Craig _______ Nutri-Systems _______
Medifast _______ Optifast _______ Other ____________________________
Exercise Program:
_____ Aerobic exercise
How often: _____ 3 days/week
_____ Water Aerobics
_____ 4 days/week
_____ Strengthening
_____ 5 days/week
_____ Upper Body
_____ > 5 days/week
_____ Walking
_____ Cardio Workout
_____ Cycling
_____ Elliptical
_____ Other Equipment ___________________________________________
Behavior Modifications:
_____ Avoid fried foods _____ Limit sugar _____ Use sugar substitute
_____ Avoid Carbonated beverages _____ Avoid Butter/Oils _____Limit sweets
_____ Practice eating slower _____ Smaller portions _____ Avoid Carbohydrates
_____ Other ________________________________________________
Ongoing Support:
_____ Patient encouraged to continue working on Diet and Exercise
_____ Patient encouraged to attend support groups offered at hospital
_____ Patient reminded that nutritional and psychological counseling are
available
_______________________________________________________________
Supervising Physician/Provider’s Signature
Please Fax this form to 901-765-3585