Physician-Supervised
Weight Loss Program
Reset Form
Monthly Assessment Form
Patient name_______________________________Contract #_______________________________
Updated measurements
Weight
Blood pressure
(lb. or kg.)
SBP/DBP
(mm Hg)
Calculated BMI
HbA1c
2
(kg/m
)
Log review
1. Did you review the patient’s daily weight log, and was it appropriately maintained?
Yes
No
2. Did you review the patient’s food diary, and was it appropriately maintained?
Yes
No
3. Did you review the patient’s activity record, and was it appropriately maintained?
Yes
No
Patient interview
1. How does the patient describe his / her progress to date?
_______________________________________________________________________________
_______________________________________________________________________________
2. How is the patient planning to maintain / improve progress going forward?
_______________________________________________________________________________
_______________________________________________________________________________
Supervising physician____________________________________________Date____________________
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