Weight Management Results Form

WEIGHT MANAGEMENT CLIENT WEEKLY SUMMARY FORM

Please try to use the same method each time you make a measurement

PLEASE MAKE SURE YOUR CLIENT NUMBER IS LISTED IN THE SPACE BELOW

Client ID: For the week ending (mm/dd/yyyy)

Height

Chest (inches)

Waist (inches)

Hips (inches)

Thighs (inches)

Weight (pounds)

Did you follow your Fit For Life Weight Management recommendations in each of the categories this past week. Yes No

If no why?

Please indicate whether you followed the recommendations given to you for the following times:

Tell Us:

= What exercises you have done this week along

= The number of exercise sessions you have accomplished and

= The number of pounds you have lost this week; and

= The total number of inches you have lost during this report period:

Thank you