Anti-Obesity Medication Initiation Note

Visit Type: [new / established]; [in-person / telehealth]

Clinician: [Name, credentials]

Primary Reason for Visit: [Initiation / Restart / Switch of anti-obesity medication for chronic weight management]

Data Sources: [patient / caregiver / outside records / EHR]

Interpreter: [Language]; [video / phone / in-person] (Only include if interpreter services were used)

Chief Concern

[Reason for visit in 1–2 sentences, optionally including the patient's own words in quotes when clinically additive] (Use person-first, non-stigmatizing language throughout the note)

History of Present Illness

[Clinical context for medication initiation including why now, weight trajectory with highest/lowest adult weight and recent changes, triggers for weight changes]

[Prior weight management attempts including nutrition programs, activity plans, behavioral therapy, prior AOMs with name/dose/duration/response/adverse effects, and bariatric procedures if applicable]

[Current lifestyle patterns – high-yield only: eating patterns and key drivers, physical activity baseline and barriers, sleep duration and OSA symptoms if present]

[Patient goals and preferences: health and functional goals beyond weight alone, route preference, tolerance for adverse effects, cost and coverage constraints]

[Functional impact and symptoms as relevant: mobility limitations, pain, dyspnea, fatigue, GERD, PCOS symptoms]

(Format as 1–3 paragraphs. If a clinically important data element was not obtained, document "not assessed today" rather than implying a negative. Omit elements not relevant to this patient.)

Obesity-Related History

• Metabolic: [prediabetes/T2D, dyslipidemia, hypertension, MASLD/MASH with status/control]
• Cardiopulmonary: [ASCVD, heart failure, OSA with therapy status, asthma]
• Musculoskeletal/Functional: [osteoarthritis, chronic pain, mobility limitations]
• Reproductive: [PCOS, infertility history]
• Other: [CKD, GERD, depression/anxiety]
• Weight-promoting medications: [psychotropics, insulin/secretagogues, steroids, others]
• Surgical history: [prior bariatric surgery, cholecystectomy, pancreatitis history]
• Targeted family history: [diabetes, premature ASCVD, medullary thyroid carcinoma or MEN2]

(Include only applicable items with status/control when known. Omit unrelated history unless it affects medication selection or safety.)

Medications and Allergies

Current Medications: [Medications with doses, emphasizing agents affecting weight, blood pressure, glucose, mood, seizure threshold, opioids, and contraception; include relevant OTC/supplements] (If reconciliation incomplete, document source used and what is pending verification)

Allergies: [Medication/substance and reaction type, noting prior AOM reactions specifically]

Reproductive Status

(Include for patients of reproductive potential)

Pregnancy Status: [pregnant / not pregnant / unknown]

Pregnancy Intention: [trying to conceive soon / future / none]

Contraception: [method and adherence concerns if applicable]

Breastfeeding: [yes / no / not applicable]

(If pregnancy status is unknown and selected medication has fetal risk, document the plan: pregnancy testing today, defer prescribing until confirmed, or choose alternative agent. Do not infer status from LMP alone when testing is clinically required.)

Targeted Review of Systems

• Cardiovascular: [chest pain, palpitations, exertional symptoms]
• Psychiatric: [depression, anxiety, suicidality current and past, substance use]
• GI/Hepatobiliary: [severe reflux, prior pancreatitis, gallbladder symptoms]
• Neurologic: [seizure history]
• Sleep: [OSA diagnosis or symptoms, CPAP use]
• Eating behaviors: [binge eating, purging, history of anorexia or bulimia]

(Use explicit responses: "denies," "reports," or "not assessed today" for each item. Limit to problem-relevant items.)

Objective

Vitals: Height [height], Weight [weight], BMI [BMI], BP [blood pressure], Pulse [pulse], Waist circumference [measurement] (Include waist circumference if measured)

Exam: [General appearance, cardiovascular, pulmonary, mood and affect, additional focused elements as indicated] (Include only elements actually performed)

Data Reviewed

• [Recent weight trend and prior measurements]
• [Pertinent labs: A1C/glucose, lipids, renal and hepatic function]
• [Sleep study results if applicable]
• [Prior AOM history from records]
• [Other relevant diagnostics or consult notes]

Labs Ordered

• [Baseline metabolic panel / renal function / hepatic function] – [indication]
• [A1C/glucose] – [indication]
• [Lipids] – [indication]
• [Pregnancy test] – [indication]
• [Medication-specific baseline labs] – [indication]

(If baseline labs deferred, document rationale: recent results acceptable, patient declined, or will obtain before dose escalation)

Assessment

Obesity / Adiposity-Based Chronic Disease

[Diagnosis term, BMI and baseline weight, weight-related complications supporting therapy, prior response to lifestyle intervention alone, readiness for pharmacotherapy]

Comorbidities Impacting Medication Selection

[Summary of conditions affecting AOM choice and their current status, e.g., blood pressure control, chronic opioid use, CKD/hepatic dysfunction, pancreatitis or gallbladder history, psychiatric stability, seizure risk]

Shared Decision-Making and Counseling

[Summary of discussion including: indication and intended health/functional outcomes; role of lifestyle as foundation with medication as adjunct; alternatives discussed; risks and benefits including common adverse effects and rare serious risks with red-flag symptoms; chronic disease framing and expectations for long-term therapy; cost/coverage considerations; patient's understanding and stated preference]

Contraindication and Precaution Screening

Universal (all AOM starts):

• Pregnancy and breastfeeding status reviewed: [yes / no]
• Severe uncontrolled psychiatric illness or active suicidality screened: [negative / positive – action taken]
• Medication list reviewed for interactions/duplications: [yes / no]
• Prior AOM reactions/intolerances reviewed: [none / present – details]

GLP-1 or dual incretin agents: (Include if prescribing this class)

• Personal/family history of medullary thyroid carcinoma or MEN2: [negative / positive / not assessed – action]
• History of pancreatitis: [negative / positive / not assessed – action]
• History of gallbladder disease: [negative / positive / not assessed – action]
• Diabetic retinopathy (if T2D): [negative / positive / not applicable]
• Planned procedures requiring anesthesia/sedation: [no / yes – counseled to inform procedural teams]
• Oral contraceptive use (tirzepatide): [no / yes – counseled regarding reduced reliability during titration]

Naltrexone/bupropion: (Include if prescribing this class)

• Uncontrolled hypertension: [negative / positive – action]
• Seizure disorder or factors lowering seizure threshold: [negative / positive – action]
• Eating disorder history (anorexia/bulimia): [negative / positive – action]
• Chronic opioid use or opioid agonist therapy: [negative / positive – action]
• Recent MAOI use: [negative / positive – action]

Phentermine/topiramate: (Include if prescribing this class)

• Pregnancy testing completed and contraception plan documented: [yes / no – action]
• Glaucoma: [negative / positive – action]
• Hyperthyroidism: [negative / positive – action]
• MAOI use: [negative / positive – action]
• Heart rate monitoring plan documented: [yes / no]
• Mood and suicidality monitoring plan documented: [yes / no]

Plan

Obesity / Weight Management

• Medication: [Generic (Brand)], [starting dose and frequency], rationale: [tied to comorbidities and patient preferences]
• Titration schedule: [Stepwise dose increases with timing, hold parameters, target/maximum dose]
• Monitoring plan: [Parameters: weight/BMI, BP, HR, glucose, adverse effects, mood]; [frequency and method]
• Response target and stop rule: [Defined metric], [decision timepoint], [action if goal not met]
• Lifestyle plan: [Nutrition approach], [activity goal], [behavioral supports]
• Referrals: [Dietitian, behavioral health, sleep medicine, bariatric surgery evaluation, medication teaching as appropriate]
• Follow-up: [Early follow-up timing for tolerability], [interval for efficacy reassessment]
• Safety net: [Red-flag symptoms requiring stopping medication, urgent evaluation, or emergency care]

Comorbidity-Specific Plans

• Diabetes: [Glucose monitoring plan, adjustments to hypoglycemia-causing agents]
• Hypertension: [Home BP monitoring plan, medication adjustment plan]
• OSA: [Baseline therapy status, monitoring plan]
• Other: [Problem-specific actions as applicable]

(Include only applicable comorbidity plans)

Orders Placed Today

• Medication: [Name, dose, quantity, refills]; supplies if injectable: [needles, alcohol swabs, sharps container]
• Labs: [Tests with indications]
• Education/Training: [Pharmacist teaching, injection training as applicable]
• Prior authorization: [submitted / pending / not required]