Program Name:
Address:
Phone:

In this program, my daily caloric intake will be:
My daily caloric intake is determined by:

The evaluation will be made by (check all that apply):
  Physician Nurse Registered Dietician Other company-trained employee

I will will not   be evaluated initially by program staff.



My progress is supervised by (check all that apply):
  Physician Nurse Licensed Psychologist Registered Dietician Company-trained employee

I will will not   be evaluated by physician during the course of my treatment.



During the first month, my progress will be monitored:
Weekly Biweekly Monthly Other


After the first month, my progress will be monitored:
Weekly Biweekly Monthly Other


My weight loss plan includes (check all that apply):
Nutrition information about healthy eating
At least 1,200 calories/day for women or 1,400 calories/day for men
Suggested menus and recipes
Keeping food diaries or other monitoring activites
Portion control
Liquid meal replacements
Prepackaged meals
Dietary supplements (vitamins, minerals, botanicals, herbals)
Prescription weight loss drugs
Help with weight maintenance and lifestyle changes
Surgery

My plan includes regular physical activity that is (check both if both apply):
Supervised (at the program site) times per week, minutes per session
Unsupervised (on my own time) times per week, minutes per session

The physical activity includes (check all that apply):
Walking
Aerobic dancing
Strength training
Stationary cycling
Swimming
Other

The weight loss plan includes (check all that apply):
Family counseling
Lifestyle modification advice
Weight maintenance advice
Weight maintenance couseling
Group support


The staff explained the risks associated with this weight loss program. They are:
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The staff explained the costs of this program. (Check all that apply and fill in the blanks.)
I will be charged a one-time entry fee of $ .
I will be charged a $ per visit.
Food replacements will cost about $ per month.
Prescription weight loss drugs will cost about $ per month.
Vitamins and other dietary supplements will cost about $ per month.
Diagnostic tests are required and will cost about $ .
Other costs include at $ .
 Total cost for this program $ .

The program gave me information about:
The health risks of being overweight.
The difficulty many people have maintaining weight loss.
The health benefits of weight loss.
How to improve my chances at maintaining my weight.

Other information to ask for:
Participants in this program have lost an average of lbs. over months/years.
Participants in this program have kept off % of their weight loss for year(s).

This information is based on the following (check one):
All participants.
Participants who completed the program.
Other

Notes:
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