Date
*
Date administered
First Name
*
Last Name
*
Email
*
Starting Weight
Latest Weight
*
Use the same scale, same time of day if possible
Goal Weight
*
Craving Level (0-10)
*
0 – No cravings 10 – Intense cravings all week
Did you take this dose the same day and time as last time?
*
Yes
No
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How would you describe your eating this week?
*
On track most days
Inconsistent
Off track
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List is empty.
How many days did you exercise or go to the gym this week?
*
0–1 days
2–3 days
4+ days
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Did you experience any challenges or side effects this week?
*
What is one win you had this week?
*
Is there anything you’d like our nurse to know about this week?
*
SUBMIT
