Weight Management Nutrition Class


Your Information

Patient First Name:

Patient Last Name:

Date of Birth:

Today's Date:

Weight:

 

Current Diet: (check those applicable)

Not following any special diet at this time

Low calorie diet (1200-1500 calories)

Jenny Craig/Weight Watchers/Quick Weight Loss

Diabetic Diet

Renal Diet

Low Fat

Low Sodium (low salt)

Other diets:

Frequency of eating away from home:

meals/week

 

Current water intake

 ounces  

Current coffee intake

 cups  

Current tea intake

 cups  

Current alcohol intake

 drinks  

Current REGULAR soda intake

 ounces  

Current DIET soda intake

 ounces  

 

Exercise

Exercise

minutes/day,

days/week

Type of Exercise:

Walking

Weight lifting

Swimming

Cycling

Other kinds of exercise:

Is an exercise/activity journal being kept?

Yes

No

Is a food journal being kept?

Yes

No

 

Goals for this month

Nutrition:

Physical Activity:

 

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