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Patient Diet & Exercise History Month 1-2-3-4-5-6- (circle one)

Patient Diet & Exercise History Month 1-2-3-4-5-6- (circle one) Patients Name:______________________________ DOB:____/____/____ Age:_____ Today’s Date:____/____/____ Ht :___ ft. ___ in. Weight:_____ Blood Pressure:_____________ Temp:_________ Weight lost/gained:_____

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Patient Diet & Exercise History Month 1-2-3-4-5-6- (circle one)

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  1. Patient Diet & Exercise History • Month 1-2-3-4-5-6- (circle one) • Patients Name:______________________________ DOB:____/____/____ Age:_____ • Today’s Date:____/____/____ Ht:___ ft. ___ in. Weight:_____ • Blood Pressure:_____________ Temp:_________ Weight lost/gained:_____ • Type of Diet (check all that apply) • Low Fat • Low Carb • Low Calorie _____________ Caloire intake amount • Other:____________________________________ • Type of Physical Activity (check all that apply) • Walking:____________________________ • Swimming :__________________________ • Aerobics :___________________________ • Bike: _______________________________ • Other:_______________________________ • Behavior Modification is being encouraged. • How many times per week is patient exercising:____________________ • Notes:_____________________________________________________________________ • __________________________________________________________________________ • Plan:______________________________________________________________________ • __________________________________________________________________________ • Physician Signature:__________________________ Office Stamp: • Office Phone Number:_______________________ • Please faxed filled out forms to 321-843-8900, along with office visit.

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