LiLy Initial Consultation Form

My Wellness Physicians

Obesity Medicine and Hormone Therapy

LiLy Collaborative · Internal Intake Tool

LiLy Initial Consultation Form

Patient & Contact

Last name

First name

DOB

Date of Service

Clinician Evaluation — SOAP Note

Completed by the provider during the visit. The structured SOAP note is generated from these sections. Leave blank to omit any line.

Fields marked auto are pre-filled from the patient's intake in the sections below. Edit any of them to override.

Subjective — HPI

Chief complaint

History of Present Illness

Builds the HPI narrative from these fields. Blank fields are skipped.

Age

Sex

Height (ft)

Height (in)

Weight (lb)

BMI (auto)

Weight status

Lipedema status

Distribution of symptoms

Bilateral lower extremity Bilateral upper extremity Hips Abdomen

Presenting symptoms (fills the bracket in the narrative)

None Heaviness Pain Swelling Easy bruising

Duration

Onset around

Pain character reported

None Pain with palpation Spontaneous pain Pressure Achiness Heaviness

Pain rating (/10)

Symptoms with standing/heat/EOD

Progression of limb size despite diet/exercise?

Yes No

Tried compression garments previously?

Yes No

Relevant negatives (no known history of…)

Lymphedema Chronic venous insufficiency Prior vein procedures

Associated Symptoms

Easy bruising of affected extremities

YesNo

Heaviness or fatigue in legs

YesNo

Pain with pressure or palpation

YesNo

Swelling worsening throughout the day

YesNo

Difficulty with mobility or gait

YesNo

Psychological distress / body image concerns

YesNo

HPI free-text override / additions (appended after the generated narrative)

Assessment

Stage/type and BMI pull from above. Add any concurrent diagnoses.

Extremity involvement

Obesity class

Concurrent diagnoses

None Insulin resistance Hypothyroidism Venous insufficiency Depression PCOS

Other concurrent diagnoses Differentials addressed (checked items print with their rationale)

Lymphedema Chronic venous insufficiency Dercum disease Lipohypertrophy

Coded Diagnoses (ICD-10)

Check each diagnosis that applies. Checked items print in the assessment with their code.

Lipomatosis NEC (E88.2) Lymphedema NEC (I89.0) Chronic venous insufficiency (I87.2) Other chronic pain (G89.29) Obesity, unspecified (E66.9) Localized edema (R60.0) Swelling R lower limb (M79.604) Swelling L lower limb (M79.605) Swelling unspec lower limb (M79.606) Hypermobility syndrome (M35.7) Hypothyroidism (E03.9) Depression (F32.A) Anxiety disorder (F41.9) Hyperlipidemia (E78.5) Essential hypertension (I10) ASHD native coronary (I25.10) Autoimmune thyroiditis (E06.3) Endometriosis (N80.9) Other fatigue (R53.83) Menopausal states (N95.1)

Plan

Check the plan items ordered today. Checked items print under their heading; defaults reflect the standard lipedema plan.

1 · Compression Therapy

None Flat-knit 20–30 mmHg Custom-fit / fitter referral Daily-wear counseling

2 · Specialist Recommendations

None Vein specialist / duplex CLT / CDT Surgical eval Psych support Dietitian

3 · Laboratory Workup

None CBC w/ diff CMP Lipid panel A1c / insulin TSH / free T4 Vitamin D Iron studies hsCRP / ESR Hormonal panel LFTs

4 · Nutrition

None Anti-inflammatory diet Keto / RAD trial Counsel on fat resistance RD referral

5 · Exercise

None Low-impact program Aquatic preferred ≥150 min/week Avoid high-impact PT/CLT coordination

6 · Additional Management

Pain management agents

Topical analgesics NSAIDs Gabapentinoids

None Weight management Skin care IPC device

7 · Follow-Up

Return to clinic in

None Reassess response Serial measurements Surgical reassess

Patient Education

Diagnosis discussed Goals reviewed Resources provided

Time spent (min)

Plan free-text additions

>50% of time spent in counseling and coordination of care.

Past Medical History

Check all conditions reported (only checked items appear in the note)

None

Cardiovascular

High Blood Pressure Heart Problems Arrhythmias High Cholesterol Heart Failure Peripheral artery disease Blood Clot Legs/Lungs Stroke

Endocrine / Metabolic

Metabolic Syndrome Insulin Resistance Diabetes I/II Gestational Diabetes PCOS Obesity Thyroid Problems Hypothyroidism Grave's Disease Hashimoto's Thyroid Nodules

Gastrointestinal

Reflux/Heartburn Stomach Ulcers Pancreatitis IBS-C/D Gluten Sensitivity/Celiac Gallbladder Problems Liver Disease Hepatic cirrhosis Fatty Liver Food Sensitivities

Musculoskeletal / Rheumatologic

Osteoarthritis Rheumatoid Arthritis Joint Pains Back/Knee Pain Gout Hypermobility/Ehlers-Danlos Fibromyalgia Lupus Mast Cell Activation Synd.

Neurologic / Psychiatric

Headaches/Migraines Peripheral neuropathy Seizures Glaucoma Depression Anxiety Insomnia Disordered eating history Drug Addiction Alcohol Abuse History

Respiratory / Renal / Other

Asthma Obstructive Sleep Apnea Chronic Kidney Disease Nephrotic Syndrome Anemia Preeclampsia/Eclampsia Thyroid Medullary Cancer MEN Type 2

Cancer (type, if any) Other past medical history / notes

Surgical History

None Gallbladder Removal Weight Loss Surgery Pelvic surgeries Prior liposuction Bariatric surgery Vein procedures

Other surgeries

Family History

Check each side affected for any condition. Leave a row blank for none. Use the blank rows to add other conditions.

Condition	Father's Side					Mother's Side					Sibling
Condition	Grandfather	Grandmother	Father	Uncle	Aunt	Grandfather	Grandmother	Mother	Uncle	Aunt	Sibling

Medications & Allergies

Takes prescription medications?

Yes No

Prescription medications

Herbal / vitamin supplements

None Multivitamin Vitamin D Omega-3 Magnesium B Complex Biotin Calcium Iron

Other supplements

Drug Allergies

No known drug allergies?

Yes (NKDA) No

Latex allergy

Yes No

Adhesive allergy

Yes No

Gynecologic & Pregnancy History

Age period started

Age period ended

Last Menstrual Period (LMP)

Periods

Regular Irregular Heavy Normal Light

Pregnancy history N/A?

N/A Applies

Pregnant / could be / planning during treatment?

Yes No

⚠ Pregnancy flag set — confirm before any treatment.

# Births

Birth dates

Birth control / procedures

None IUD Pills Patch Ring Condoms Vasectomy Tubal Ligation Hysterectomy

Hysterectomy detail (when / partial-complete / why) GYN comments

Social History

Caffeine

Caffeine use (note cups/cans per day in detail field)

None Coffee Tea Cola Energy drinks

Alcohol

None Wine Beer Liquor

Tobacco

None Socially Former smoker Vapes

Lifestyle & Support

Activity level Occupation Diet history (current pattern / prior diets) Psychosocial support

Review of Systems

WOMEN ONLY

None Absence of periods Abnormal menstruation Hot Flashes Facial Hair Change in bladder habits

Check all symptoms reported

None

Constitutional / Endocrine

Wt loss >10lb Wt gain >10lb Increased appetite Decreased appetite Fatigue Weakness/low energy Excessive sweating Cold intolerance Heat intolerance

Skin / HEENT

Skin rash Acne Hair/Nail changes Blurred vision Double vision Dysphagia

Respiratory / Cardiovascular

Snoring Difficulty breathing flat SOB Cough Chest pain on exertion Palpitations

Gastrointestinal

Gas/Bloating Indigestion Heartburn Abdominal pain Constipation Diarrhea Blood in stool Nausea/Vomiting Food intolerance

Genitourinary

Urinary frequency Slow urine flow Nighttime urination Low libido

Neurologic / Psychiatric

Memory loss Seizures Can't concentrate Headaches Dizziness Fainting Nervousness Anxiety Depression Mood changes Insomnia

Musculoskeletal / Extremities

Back pain Muscle aches Joint pains Swollen ankles Varicose veins Leg pain standing Leg cramps Leg swelling

Weight History

Ideal weight (lbs)

Highest weight (lbs)

Lowest weight (lbs)

How does weight affect life and health? First noticed weight gain

Childhood Teens Adulthood Pregnancy Peri/Menopause

Ever gained >20 lb in <3 months?

Yes No

Weight 1 yr ago

5 yrs ago

10 yrs ago

Life events associated with weight gain

Marriage Divorce Pregnancy Abuse Illness Travel Injury Nightshift work Job change Quitting smoking Alcohol Drugs Medication

Previous weight-loss programs tried (check all that apply)

None Weight Watchers Nutrisystem Jenny Craig Keto Diet Atkins South Beach Zone diet Medifast Mediterranean DASH diet Paleo diet Ornish diet HCG diet Other

Weight-loss medications tried (check all that apply)

Semaglutide Tirzepatide Belviq Bupropion (Wellbutrin) Contrave Diethylpropion Meridia Metformin Orlistat Phendimetrazine (Bontril) Phen/Fen Phentermine (Adipex) Qsymia Saxenda Topamax Xenical/Alli None

Other weight-loss medication / supplement What worked / didn't work (optional) Max weight loss & how achieved Greatest challenges with weight loss

Counseling/therapy for weight management?

Yes No

Emotional factors influence eating?

Yes No

Nutrition & Eating

Currently on a special diet?

Yes No

Low Fat Low Salt Carb Controlled Gluten Free Dairy Free

Diet detail / who prescribed / other

Eating Disorder Screen

Toggle any reported. Flags appear in note in section order.

None Anorexia tx Bulimia tx Binge-eating tx Purging tx Laxative use Eats lg amt alone

Eating disorder detail / treatment dates

Eating Habits

Night eating No memory of eating Skips meals Craves sweets Fasts Vegetarian/Vegan Can't-live-without foods Chew/swallow trouble

Meals per day

1 meal 2 meals 3 meals 1-2 meals 2-3 meals >3 meals

Meals skipped

Snacking pattern

a.m. p.m. evening between all meals grazes all day

Beverage notes (soda, juice, sweet tea, milk, etc.) Eating notes

Physical Activity & Sleep

Enjoys physical activity

Days/week mod-vigorous activity

Minutes per bout

Activities done regularly

Walking Biking Strength Yoga Pilates

Barriers to activity Equipment / activities enjoyed (notes)

Sleep

Avg hours/night

Usual bedtime

Usual waking time

Night/shift work?

Yes No

Sleep concerns reported

Trouble sleeping Not rested Daytime tired Snores Observed apnea AM headaches Naps Sleep eval done Dx sleep apnea

CPAP/BiPap device (if applicable)

Occupation, Home Life & Mental Health

# in household

Occupation

Good social support for lifestyle change?

Yes No

Support people / partner's attitude (notes)

Mental Health

Is stress a major problem?

Yes No

Healthy coping mechanisms?

Yes No

How they cope with stress

Considers self an "emotional eater"?

Yes No

Diagnosed mental health condition?

Yes No

Which condition(s)

Anxiety Depression Bipolar

Ever been to a counselor / mental health professional?

Yes No

Currently receiving counseling? (detail)

Safety Screen

Ever seriously thought about hurting self?

Yes No

Ever attempted suicide?

Yes No

⚠ Safety screen positive — flag for clinician review.

Visit Details

Date completed

Completed/entered by

Attestation reviewed & signed by patient?

Yes Pending

Additional notes

📋 CRM Note (auto-generated)

Paste directly into the patient record in your CRM. No data is saved or transmitted.

My Wellness Physicians · LiLy Collaborative · Internal Intake Tool · mywellnessphysicians.com · 703-777-9355