Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
(Optional) May document any weight-related concerns the patient expresses,
such as difficulty exercising, limitations due to weight, or motivational
challenges.
History of Present Illness:
Duration of weight concerns.
Attempts at weight loss (dietary changes, exercise programs, medications
or surgical history).
Successes and challenges with previous weight loss attempts.
Any new or worsening symptoms potentially related to obesity (e.g.,
shortness of breath, joint pain, sleep apnea).
Past Medical History:
(List any relevant medical conditions)
Diabetes mellitus
Hypertension
Hyperlipidemia (high cholesterol)
Sleep apnea
Osteoarthritis
Fatty liver disease
Cardiovascular disease (history of stroke, heart attack)
Polycystic ovary syndrome (PCOS)
Social History:
Dietary habits (eating patterns, portion sizes, typical food choices).
Physical activity level (frequency, duration, intensity of exercise).
Social support for weight management efforts (encouragement from family
and friends).
Occupational factors that may impact weight management (e.g.,
sedentary
job, shift work, limited access to healthy food options).
Family History:
Family history of obesity or weight-related complications (e.g., diabetes,
hypertension).
Physical Exam:
Vital signs (blood pressure, heart rate).
Body mass index (BMI) and weight circumference.
Physical examination findings suggestive of obesity-related comorbidities
(e.g., acanthosis nigricans – dark, velvety skin patches, joint tenderness).
Laboratory Tests:
(As indicated based on history and physical exam)
Fasting blood sugar or HbA1c (glycemic control)
Lipid panel (cholesterol levels)
Thyroid stimulating hormone (TSH) (rule out thyroid disorders)
Assessment:
Obesity: Diagnosed based on BMI (body mass index)
Overweight: BMI 25.0-29.9 kg/m²
Obesity: BMI 30.0 kg/m² or greater
Further classification of obesity (Class I, II, or III) based on BMI
severity.
Comorbid conditions: List any obesity-related medical conditions
identified.
Motivation for weight loss: Assess patient’s interest and readiness
for lifestyle changes.
Plan:
Goal setting: Establish realistic and measurable weight loss goals
(e.g., aim for a 5-10% weight loss in 6 months).
Dietary modifications: Discuss dietary changes to promote weight loss
(e.g., portion control, healthy food choices, reducing calorie intake).
Physical activity: Develop an exercise plan considering patient’s
abilities and preferences (e.g., recommend gradual increase in activity
duration and intensity).
Behavioral counseling: Discuss strategies for behavior change
(e.g., self-monitoring, stress management, addressing emotional eating).
Medications or Surgery (if appropriate): Discuss potential
medications or surgical interventions for weight management in eligible
patients based on individual factors and provider expertise.
Follow-up: Schedule follow-up appointments to monitor progress,
adjust the plan as needed, and provide ongoing support and motivation.
Additional Resources:
Provide information about educational resources or support groups
available to help patients with weight management.