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(Including City, State, Zip)

Providing this information will help ensure a smooth PA process

If prescribed a non weight loss medication, please list the medication name here.

(month and year)

(mg, size of pill, strength)

(once a day, twice a day, once a week etc)

(specific side effects, treatment failure, allergy or other)

To correctly measure waist circumference: Stand and place a tape measure around your middle, just above your hipbones.Make sure tape is horizontal around the waist.Keep the tape snug around the waist, but not compressing the skin.Measure your waist just after you breathe out.

Please add any additional information that may be helpful, questions, or put N/A.

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