PROGRESS EVALUATION I
Patient Progress Evaluation Form
Patient Name *
Date
Appointments & Compliance
Have there been any missed appointments?
Yes
No
Is the patient doing home rehabilitation?
Yes
No
Weight Tracking
Starting Weight
Current Weight
Target Weight
Lifestyle & Improvements
Patient lifestyle willingness score (0–10)
5
Nutrition improvement (1–10)
1
2
3
4
5
6
7
8
9
10
Mindset improvement (1–10)
1
2
3
4
5
6
7
8
9
10
Exercise improvement (1–10)
1
2
3
4
5
6
7
8
9
10
Toxin reduction improvement (1–10)
1
2
3
4
5
6
7
8
9
10
Medications
Has the patient reduced medications?
Yes
No
Is the patient up to date on vaccinations?
Yes
No
Any new medications?
Yes
No
Does patient need drug information?
Yes
No
Notes & Questions
Specific health issues noted?
Any program questions from patient?
Additional Notes
Signatures
Patient Signature *
Sign here with your finger or stylus
Provider/Doctor Signature
Sign here with your finger or stylus
Submit Progress Evaluation I