Patient Information

First Name

Last Name

Date of Birth: MM/DD/YYYY

Email

Contact Information

Pharmacy Name (required)

Pharmacy Address (required)

Medication Name (required)

Medication Dosage (required)

1. Are you happy with your current weight loss progress and treatment plan? 1. Are you happy with your current weight loss progress and treatment plan? Yes No

2. What is today's weight (lbs)?

3. How much weight (lbs) have you lost since starting the weight loss program?

4. How often do you weigh yourself and is the weigh-in performed every morning after your first void?

5. Have you experienced any problems with the program, medications, or diet? 5. Have you experienced any problems with the program, medications, or diet? Yes No

6. How much weekly exercise are you performing after starting this weight loss program?

7. Daily hydration is essential! How much water water are you drinking daily (oz)?

8. What works best for you when trying to lose weight?

9. What's holding you back from weight loss success?

10. Have you visited with a Registered Dietician? 10. Have you visited with a Registered Dietician? Yes No