200 Pharmacy Wellness Tracker

• Your Name: First Last
• Your ID Number:
• Your Week Interval Began On: / MM / DD YYYY
• Your Current Weight (in pounds):
• Pedometer Reading for the week:
• Waist Measurement this week:
• How often this week did you follow the plate diet:
  For a few meals (1-5 times) Some of the time (6-10 times) A majority of the time (11-15 times) All of the time (16 - 21 times)