Weight Loss Medication
Monthly Progress Assessment
Name
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Working Diagnosis
*
Current Weight
*
Average Steps per Day (for past month)
*
Number of sweetened beverages in the past Day (24 hrs)
*
Blood Pressure
*
Last Appointment Date
*
Medication Names & Dose
*
Any New Issues or Questions?
*
Please mark any of the following that apply:
constipation
diarrhea
change in taste
inability to fall asleep
headache
jerking movements or tremor
emotional irritability
change in libido
rash
palpitations or rapid heart rate
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*
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