Anti-Obesity Medication Follow-Up/Titration Note

Date: [Date]

Encounter Type: [in-person / telehealth]

Reason for Visit: AOM follow-up/titration

Chief Concern

[Primary concern for this visit in one line]

Interval History

[Time since last visit] — [Current AOM regimen: medication name, dose, route, frequency]

• Weight Trajectory: [Current weight with date and source (clinic scale / patient-reported)]; [Prior weight(s) with dates]; [Net change since last visit]; [Net change since treatment baseline]; [%TBWL with calculation: ([baseline weight] − [current weight]) ÷ [baseline weight] × 100] (Include waist circumference only if measured. Distinguish measured vs patient-reported. Include dates for all trend data.)
• Medication Adherence: [Number of missed doses and reasons]; [Current titration step]; [Administration technique issues]; [Access/supply status]
• Tolerability and Adverse Effects: [Brief narrative covering GI symptoms, appetite/nutrition impact, and class-relevant concerns]; [Statement confirming absence of red-flag symptoms when appropriate]
• Lifestyle Adherence: [Nutrition pattern changes]; [Physical activity]; [Behavioral supports]; [Barriers encountered]
• Perceived Benefit: [Patient-reported changes in satiety, cravings, eating control, mobility, function, quality of life]

(If any domain above was not assessed or obtained, state this explicitly rather than omitting.)

Objective

• Vitals: [BP]; [HR]; [Weight]; [BMI] (Mark patient-reported values if telehealth. If unavailable, state reason.)
• Exam: [Clinically relevant findings only: general appearance, hydration, injection site if indicated, mental status if monitoring neuropsychiatric concerns, abdominal exam if symptomatic] (Omit comprehensive exam unless clinically indicated.)
• Data: [Pertinent labs with dates]; [Device data if used] (State if labs not obtained, pending, or planned.)

Assessment

Primary problem: Obesity/weight management with [current BMI] and [%TBWL since baseline]. Response: [effective / suboptimal / limited by tolerability / contraindicated]. [Contributing factors affecting response].

Weight-related comorbidities: [Brief status update with trend data and dates for relevant conditions] (Note correlation with weight change where relevant.)

Plan

• Medication Decision: [continue current dose / titrate up / titrate down / hold / stop / switch] — [Rationale] (This explicit statement is required.)
• Dosing: [Current dose and administration instructions]; [Next planned dose change with timing]; [Missed dose guidance]; [Supportive medications if used]
• Safety Monitoring: [Agent- and patient-specific monitoring plan: vitals frequency, lab timing, pregnancy prevention/testing as applicable]; [Urgent symptoms requiring immediate evaluation]
• Comorbidity Adjustments: [Changes to diabetes or blood pressure medications]; [Referrals or other management updates] (Omit if none.)
• Lifestyle Goals: [1–3 specific, measurable goals until next visit]
• Follow-up: [Timing of next visit]; [Modality]; [Triggers for earlier contact]

(Do not infer adherence, side effects, or pregnancy status. Distinguish measured vs patient-reported values. Include dates for all trend data.)