Tel: 304. 388. 4965
Fax: 304. 388. 4968
Weight Loss Program, Diet , Exercise History
|
Tel: 304. 388. 4965 |
|
|
|
|
Weight Loss Program, Diet , Exercise History |
|
|
|
|
| Name of Physicians Dates and Length of time | |
|
|
|
| Medications Dates and Length of time taken | |
|
|
|
| Organized Diet Programs (Weight Watchers, TOPS, etc) Dates and Length of time | |
|
|
|
| Organized Exercise Programs Dates and Length of time | |
|
|
|
| Name___________________________ Signature___________________________ Date________ | |