________________ ________________ ________________

________________ ________________ ________________

N° MEM: N° MEM: N° MEM:

_____Kg _____Kg _____Kg

_____m _____m _____m

_____%HbA1c _____%HbA1c _____%HbA1c

________________ ________________ ________________

________________ ________________ ________________

N° MEM: N° MEM: N° MEM:

_____Kg _____Kg _____Kg

_____m _____m _____m

_____%HbA1c _____%HbA1c _____%HbA1c

________________ ________________ ________________

________________ ________________ ________________

N° MEM: N° MEM: N° MEM:

_____Kg _____Kg _____Kg

_____m _____m _____m

_____%HbA1c _____%HbA1c _____%HbA1c

________________ ________________ ________________

________________ ________________ ________________

N° MEM: N° MEM: N° MEM:

_____Kg _____Kg _____Kg

_____m _____m _____m

_____%HbA1c _____%HbA1c _____%HbA1c