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Hx of appetite suppressants or other weight loss methods?
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Past Medical History (Diagnosis, i.e. thyroid, cancer, ect)
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Beverages (water intake, coffee, energy drinks, tea, soda, etc)
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Exercise (Cardio, Weight Training. How long, how many times a week)
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Allergies to medication?
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Goal Weight
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OBJECTIVE
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PHYSICAL EXAM
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ASSESSMENT
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ASSESSMENT
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PLAN
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PROVIDER PLAN
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Signed off by
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MA PLAN
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