Weight Loss Management – Medication Refill Form

This follow up assessment is designed to obtain information about your current weight and diet, your current health status, and your current eating and exercise habits. Please complete the questionnaire carefully. Incomplete forms/missing information would be an invalid refill request.

Patient Information

1. Are you happy with your current weight loss progress and treatment plan?

Yes No

5. Have you experienced any problems with the program, medications, or diet?

Yes No

10. Have you visited with a Registered Dietician?

Yes No

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