Patient & Visit

Last name

First name

Date of Birth

Date of Service

Chief complaint

2

History of Present Illness

Current weight (lbs) Height (inches) Goal weight (lbs) Highest weight ever (lbs) Weight one year ago (lbs) When did weight gain begin? (check one) Weight gain/loss details

3

Past Medical History

Check all that apply

Cardiovascular & Metabolic

Endocrine & Glucose

Thyroid & Endocrine

Thyroid problems Grave's disease Hashimoto's Thyroid nodules

Gastrointestinal

Respiratory & Vascular

Asthma Sleep apnea Blood clot in lungs

Rheumatologic & Kidney

Neurologic & Peripheral Vascular

Mental Health & Behavioral

Lipedema & Other

Lipedema

Cancer

Thyroid medullary cancer Multiple endocrine neoplasia type 2

Other cancer or medical conditions

4

Family History

List conditions reported. Check each side affected.

Condition	Father's Side					Mother's Side
	GF	GM	Father	Uncle	Aunt	GF	GM	Mother	Uncle	Aunt
Lipedema - suspected
Obesity
Venous Disease
Lymphedema
Breast Cancer
Ovarian Cancer
Uterine Cancer
Diabetes
Heart Attack <55
Heart Attack 55+
Hypertension
High Cholesterol
Mental Illness
Osteoporosis
Stroke

5

Surgical History

Prior weight loss surgery?

No Yes

Other surgeries (include dates)

6

Medications & Allergies

Current medications

Drug allergies?

NKDA Yes

Supplements/vitamins

7

Social History

Tobacco use

Tobacco details (if applicable)

Alcohol use

Alcohol details (if applicable)

Caffeine use

Caffeine details (if applicable) Occupation Living situation & social support

8

Review of Systems

Check all that apply

Constitutional

Recent weight loss > 10 LBS Recent weight gain > 10 LBS Increased appetite Decreased appetite Fatigue Mood changes Excessive sweating

Skin / Hair / Nails

Skin rash Acne Hair / Nail changes

Eyes / Vision

Blurred vision Double vision

Respiratory

Dysphagia / Difficulty swallowing Snoring Difficulty breathing when flat Shortness of breath Cough

Cardiovascular

Palpitations Chest pain on exertion

Gastrointestinal

Genitourinary

Urinary frequency / urgency Slow urineflow Night time urination Low libido

Neurological / Psychiatric

Musculoskeletal / Extremities

Other

Weakness / low energy Cold intolerance Heat intolerance

9

Eating Habits & Weight Loss History

Eating patterns (check all that apply) Prior weight loss attempts Prior weight loss medications tried Greatest challenges with weight loss

Prior counseling for weight management?

No Yes

10

Physical Activity & Sleep

Current physical activity level Type of activities Barriers to physical activity Average hours of sleep per night Sleep issues (check all that apply) CPAP or sleep device use?

11

Women's Health (if applicable)

Menopausal status Menstrual history Current hormonal therapy

Pregnant or planning pregnancy?

No Yes

12

Mental Health & Stress

Stress level (1-10 scale) Mental health history (check all that apply) Current mental health treatment

Suicidal ideation or self-harm history?

No Yes

13

Objective - Physical Exam

Exam type

Physical examination

14

Assessment

Clinical impressions & diagnoses

15

Plan - Medication

Weight loss medication plan

Mechanism of action and potential side effects reviewed with patient.

16

Plan - Nutrition & Supplements

Nutrition recommendations

High protein (30-50g/meal) Fiber 25-35g/day Water 80-100 oz/day Limit alcohol & refined carbs Use food tracking app

Nutrition recommendations (detailed) Supplements to start

Multivitamin Vitamin D3 B12

Supplements to start (detailed)

16

Plan - Exercise

Exercise prescription

Resistance training priority 150 min/week aerobic

17

Plan - Labs & Referrals

Labs to order Referrals (check all that apply) Referral notes (if applicable)

18

Plan - Follow-Up

Follow-up 2-3 weeks Phone check-in 1 week Contact clinic sooner if needed

18

Time Documentation for Billing

Patient status

Total time on encounter

My Wellness Physicians

Weight Loss New Patient SOAP Note

Patient & Visit

History of Present Illness

Past Medical History

Family History

Surgical History

Medications & Allergies

Social History

Review of Systems

Eating Habits & Weight Loss History

Physical Activity & Sleep

Women's Health (if applicable)

Mental Health & Stress

Objective - Physical Exam

Assessment

Plan - Medication

Plan - Nutrition & Supplements

Plan - Exercise

Plan - Labs & Referrals

Plan - Follow-Up

Time Documentation for Billing

📋 CRM Note (auto-generated)