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12
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1
Name
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2
What were your successes this week?
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3
Are there any specific topics you would like to discuss today?
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4
How have you been feeling physically this week compared to other weeks?
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5
Did anything happen this week that you would like your dietitian to know about (specific challenges, difficult moments, successful moments, new experiences, other?)?
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6
Has there been any change in your medication (type, dosage)?
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7
Were there any foods you rediscovered this week?
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8
Please describe your fluid intake (what, how much) this week.
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9
Please describe your activity this week.
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10
How many days did you take your vitamin/other supplements - if you are taking any - this week.
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11
When is your next medical appointment?
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12
Today's date
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Date
Month
Day
Year
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