PatientPop



FOLLOW-UP FOR ESTABLISHED PATIENT (Internal Use Only)Patient’s Name:_____________________________________ Date:____/____/______Reason for Follow Up: Obesity evaluation and treatmentTreatment Responses:Nutrition Plan: Low-calorie diet Modified low-calorie dietKetogenic dietLow-carb diet Meal replacementsMaintenance Other: _______________________________________Calories per day: __________ Carbs per day:__________How often have you been able to stay on program? AlwaysUsually Rarely NeverMedication(s):Appetite well controlled? Yes NoHow hungry? (not hungry) 1 2 3 4 5 6 7 8 9 10 (starving)Focus: GoodFairPoorSide effects? Yes No Any recent change in medication(s)?Yes NoSide effects noted:HungerFluid retentionLeg achesLight headednessLack of focusNauseaVomitingDiarrheaConstipationMood swingsEnergyInsomniaIndigestionIrritabilityHeadachesRapid heart rateFeeling weakDepressionInjection site irritationShortness of breathCravings (general)Cravings(carbs)DizzinessRashSatietyLow blood sugarFeeling coldHair lossOther:Exercise: Frequency:__________ x per weekLength of Time:__________ min Type of Exercise: Cardio Resistance/strength trainingOther: _____________________________________Starting weight: __________Date:____/____/______Today’s weight:__________ Percent weightlost:__________BP: __________/_________Pulse: __________ExamGeneralHEENTNeckRespCVGIDermExtremitiesDiagnosis:E66.9 ObesityE66.3 OverweightE66.01 Obesity due to excess calorieE66.2Obesity with alveolar hypoventilationR63.5 Abnormal weight gainE88.81 Metabolic syndromeE28.2 PCOSE78.2Mixed hyperlipidemiaF50.9EatingD/OE78.5 HyperlipidemiaunspecifiedE11.9T2DMwithoutcomplicationE78.1 Purehyper-triglyceridemiaK76.0FattyliverZ71.3DietarycounselingE55.9Vitamin DdeficitI10EssentialHTNE11.65T2DM withhyperglycemiaE03.9Hypo-thyroidismZ68.25BMI 25-25.9Z68.26BMI 26-26.9Z68.27BMI 27-27.9Z68.28BMI 28-28.9Z68.29BMI 29-29.9Z68.30BMI 30-30.9Z68.31BMI 31-31.9Z68.32BMI 32-32.9Z68.33BMI 33-33.9Z68.34BMI 34-34.9Z68.35BMI 35-35.9Z68.36BMI 36-36.9Z68.37BMI 37-37.9Z68.38BMI 38-38.9Z68.39BMI 39-39.9Z68.41BMI 40-44.9Z68.42BMI 45-49.9Z68.43BMI 50-59.9Z68.44BMI 60-69.9Z68.45BMI ≥ 70.0Z71.89Exercise counselingE65Localized adiposityPlan:Nutrition: Low-calorie diet Modified low-calorie dietKetogenic diet Low-carb dietMeal replacements Maintenance Refer to RD/nutritionist FITTE: CardioResistance exercises ACSM recommendations (150 minutes/week in active weight loss)Behavior: Motivational interviewing performed Referral for counseling Discussed strategies to overcome habits/challenges for focusMedications: Phentermine _______ mg as directed _______#_______RX/dispensedDiethylpropion _______ mg as directed _______# _______RX/dispensedPhendimetrazine_______ mg as directed _______#_______RX/dispensedMetformin _______ mg as directed _______#_______RX/dispensedQsymia ________________________________________________________Contrave 2 tabs BID #120-OR-Contrave titrate as directed #70Belviq 10mg BID #60-OR-Belviq 20mg daily #30 Saxenda 3mg (18mg/3ml) #5 pens/month supply. Novo Fine needles box of 100 use as directed. Titrate weekly as directed until maximum dosage of 3.0mg Other: _________________________________________________________Reviewed:Nutrition and the importance of regular protein intakeLabs ordered: A1C FBS LipidsTSH/TFTCMPLFTHidden CHO/carbohydrate sourcesAlcohol as possible source of hidden/amnesia calories and its effects Importance of physical activity and reducing sedentary timeTreatment plan Discussed that use of phentermine/diethylpropion/phendimetrazine/benzphetamine for more than 90 days is considered off-labelComments: __________________________________________________________________RTO: _____ weeksProvider’s signature:________________________________ ................
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