Managed

WeightControlDiary

S tar t:

DAY 1
Morning.

Xenical

Foods Eaten

Yes

No

How much

Comments

Afternoon.
Foods Eaten

Comments

Xenical

Yes
How much

No

Evening.

Xenical

Foods Eaten

Yes

No

How much

Comments

Physical Activity
Activities

How long

Comments

Stool Index
0

0 = no stool today, 1 = normal stool, 2 = oily stool, 3 = soiling or leakage, 4 = loose stool

DAY 2
Morning.

Xenical

Foods Eaten

Yes

No

How much

Comments

Afternoon.
Foods Eaten

Comments

Xenical

Yes
How much

No

Evening.

Xenical

Foods Eaten

Yes

No

How much

Comments

Physical Activity
Activities

How long

Comments

Stool Index
0

0 = no stool today, 1 = normal stool, 2 = oily stool, 3 = soiling or leakage, 4 = loose stool

DAY 3
Morning.

Xenical

Foods Eaten

Yes

No

How much

Comments

Afternoon.
Foods Eaten

Comments

Xenical

Yes
How much

No

Evening.

Xenical

Foods Eaten

Yes

No

How much

Comments

Physical Activity
Activities

How long

Comments

Stool Index
0

0 = no stool today, 1 = normal stool, 2 = oily stool, 3 = soiling or leakage, 4 = loose stool

DAY 4
Morning.

Xenical

Foods Eaten

Yes

No

How much

Comments

Afternoon.
Foods Eaten

Comments

Xenical

Yes
How much

No

Evening.

Xenical

Foods Eaten

Yes

No

How much

Comments

Physical Activity
Activities

How long

Comments

Stool Index
0

0 = no stool today, 1 = normal stool, 2 = oily stool, 3 = soiling or leakage, 4 = loose stool

DAY 5
Morning.

Xenical

Foods Eaten

Yes

No

How much

Comments

Afternoon.
Foods Eaten

Comments

Xenical

Yes
How much

No

Evening.

Xenical

Foods Eaten

Yes

No

How much

Comments

Physical Activity
Activities

How long

Comments

Stool Index
0

0 = no stool today, 1 = normal stool, 2 = oily stool, 3 = soiling or leakage, 4 = loose stool

DAY 6
Morning.

Xenical

Foods Eaten

Yes

No

How much

Comments

Afternoon.
Foods Eaten

Comments

Xenical

Yes
How much

No

Evening.

Xenical

Foods Eaten

Yes

No

How much

Comments

Physical Activity
Activities

How long

Comments

Stool Index
0

0 = no stool today, 1 = normal stool, 2 = oily stool, 3 = soiling or leakage, 4 = loose stool

DAY 7
Morning.

Xenical

Foods Eaten

Yes

No

How much

Comments

Afternoon.
Foods Eaten

Comments

Xenical

Yes
How much

No

Evening.

Xenical

Foods Eaten

Yes

No

How much

Comments

Physical Activity
Activities

How long

Comments

Stool Index
0

0 = no stool today, 1 = normal stool, 2 = oily stool, 3 = soiling or leakage, 4 = loose stool

 Hoffmann-LaRoche, Ltd.
Pharmaceuticals Division
CH - 4070 Basel

Visit our internet website:

W W W. RO C H E - O B E S I T Y. N E T
12/11/1997, F. Hoffmann-LaRoche, Ltd.