Patient & Visit

Last name

First name

Date of Service

Visit type

Chief complaint

2

Current Medication & Adherence

Current medication

Dose (mg)

Frequency

Missed any doses since last visit?

Yes No

If yes, details (how many / why)

3

Side Effects

Reported side effects (check all that apply)

Bowel movement changes

Additional side effect notes

4

Medication Effect

Felt effects of the medication?

Yes No

Decreased appetite?

Yes No

Decreased food noise?

Yes No

Feels fullness / satiety?

Yes No

5

Nutrition

Tracking caloric intake?

Yes No

Protein intake (g/day)

Fiber intake (g/day)

Skipping meals?

Yes No

6

Physical Activity

Current activity description Activity types (check all that apply)

Going to the gym Walking Weight lifting / resistance training Working with a personal trainer Group classes

Weight lifting — times per week

Personal trainer — sessions per week

7

Health Maintenance & Sleep

Seen primary care recently?

Yes No

Any changes since last PCP visit?

Getting adequate sleep?

Yes No

Any medication changes since last seen?

Yes No

If yes, details (medication, dose, who prescribed)

8

Objective — Physical Exam

Patient-reported weight (lbs, home scale)

Exam type

Physical exam

9

Assessment

Clinical impressions / diagnoses

10

Plan — Medication

Medication plan

Mechanism of action and potential side effects reviewed with patient for all options.

11

Plan — Nutrition, Hydration & Supplements

Prescribed daily calorie goal (kcal/day)

Nutrition Goals

Protein 30–50g/meal Fiber 25–35g/day Limit alcohol No eating after 8 PM Encourage food tracking apps

Hydration

Water 80–100 oz/day Limit caffeine

Supplements

MVI + probiotic

12

Plan — Exercise

Exercise plan

Emphasize weight training Discuss PT referral

13

Plan — Labs and Diagnostics

14

Plan — Referrals

None Refer to cardiologist Refer to vein specialist Refer to registered dietitian Refer to rheumatologist Refer to allergist

Referral notes (reason, urgency, provider name if known)

15

Plan — Follow-Up

Follow-up next week (labs/finalize) Return in 4 weeks Contact clinic sooner if needed

16

Time Documentation for Billing

Patient status

Total time on date of encounter

My Wellness Physicians

Weight Loss Follow-Up SOAP Note

Patient & Visit

Current Medication & Adherence

Side Effects

Medication Effect

Nutrition

Physical Activity

Health Maintenance & Sleep

Objective — Physical Exam

Assessment

Plan — Medication

Plan — Nutrition, Hydration & Supplements

Plan — Exercise

Plan — Labs and Diagnostics

Plan — Referrals

Plan — Follow-Up

Time Documentation for Billing

📋 CRM Note (auto-generated)