Anti-Obesity Medication Initiation Note

Date: [Date]

Clinician: [Clinician name, credentials]

Patient: [Patient name or identifier]

Reason for Visit: Anti-obesity medication initiation

Measurement Source: [clinic-measured / patient-reported]; [date if carried forward]

Clinical Summary

• [Diagnosis and eligibility snapshot including baseline weight, BMI, and qualifying weight-related complication if BMI < 30]
• [Medication selected and rationale for why this agent fits patient goals/comorbidities; why alternatives not chosen]
• [Contraindication screen result confirming key agent-specific items reviewed; state if none identified or list critical findings]
• [Counseling confirmation that risks, benefits, and alternatives discussed and patient agrees to plan]
• [Response target and follow-up timing]

Subjective

Patient Goals: [Patient-stated goals for weight, function, symptoms, and/or quality of life] (Use brief patient voice when helpful for preference-sensitive choices.)

Relevant History: [Weight trajectory, structured lifestyle programs, prior anti-obesity medications, bariatric procedures, current lifestyle pattern] (Include only information relevant to today's decision. Reference prior documentation by date rather than repeating unchanged details.)

Medical Context Affecting AOM Choice: [Comorbidities influencing selection, weight-affecting medications, relevant substance use]

Reproductive Status: [Pregnancy status/intent, contraception, breastfeeding] (Include only if relevant to the selected agent.)

Objective

Anthropometrics: [Height]; [Weight]; [BMI]; [BP]; [HR]; [Waist circumference if obtained]

Exam: [Pertinent focused examination findings by system] (Document only systems examined today.)

Data reviewed today: [Relevant baseline labs/tests with dates and results]

Orders placed today: [Baseline labs/tests ordered]

Assessment

[Diagnosis statement with obesity/overweight severity and weight-related complications]

Eligibility: Meets criteria for AOM because [BMI threshold and/or qualifying comorbidity]. Lifestyle intervention [ongoing / completed / insufficient response]. Medication appropriate now because [clinical rationale].

Plan

Shared Decision-Making: [Patient goals discussed; options reviewed including lifestyle alone, chosen AOM, and alternative pathway; rationale for chosen agent; patient understanding and agreement documented] (Avoid generic statements like "R/B/A discussed.")

Contraindication/Precaution Screen

Selected agent: [Agent name (generic/brand) and class]

General safety checks:

• Hypersensitivity to components: [Yes / No / Unknown]
• Pregnancy assessed: [Yes / No / Unknown]
• Breastfeeding assessed: [Yes / No / Unknown]
• Drug interaction/duplication check: [Yes / No]

Agent-specific contraindications/precautions: (Include only the section for the selected agent.)

• GLP-1/GIP agonists: Personal/family history MTC or MEN2: [Yes / No / Unknown]; History of pancreatitis: [Yes / No / Unknown]; Severe GI disease: [Yes / No / Unknown]; Gallbladder disease: [Yes / No / Unknown]; Renal impairment with dehydration risk: [Yes / No / Unknown]
• Naltrexone/bupropion: Chronic opioid use or withdrawal: [Yes / No / Unknown]; Seizure disorder or lowered threshold: [Yes / No / Unknown]; Uncontrolled HTN: [Yes / No / Unknown]; Eating disorder history: [Yes / No / Unknown]; MAOI within 14 days: [Yes / No / Unknown]; Suicidal ideation/unstable mood: [Yes / No / Unknown]
• Phentermine/topiramate ER: Pregnancy with contraception plan: [Yes / No / Unknown]; Glaucoma: [Yes / No / Unknown]; Hyperthyroidism: [Yes / No / Unknown]; MAOI within 14 days: [Yes / No / Unknown]; Nephrolithiasis/metabolic acidosis: [Yes / No / Unknown]; Unstable CV disease: [Yes / No / Unknown]
• Orlistat: Chronic malabsorption: [Yes / No / Unknown]; Cholestasis: [Yes / No / Unknown]; Warfarin/cyclosporine/levothyroxine interactions addressed: [Yes / No / Unknown]; Fat-soluble vitamin plan: [Yes / No]
• Phentermine (short-term): CV disease or uncontrolled HTN: [Yes / No / Unknown]; Hyperthyroidism or glaucoma: [Yes / No / Unknown]; MAOI within 14 days: [Yes / No / Unknown]; Substance use disorder history: [Yes / No / Unknown]

Mitigation plan for Yes/Unknown items: [Follow-up actions, additional testing, or deferral plan]

Prescription

Medication: [Generic (Brand)], [Dose], [Route], [Frequency]

Titration schedule: [Stepwise titration plan with dates/weeks]

Quantity/refills: [# units] with [#] refills

Administration: [Timing, food, injection technique if applicable]

Missed-dose guidance: [Agent-specific instructions]

Counseling Provided

• Expected benefits and timeline: [Anticipated weight loss range and time to response]
• Common side effects and mitigation: [Key side effects with strategies]
• Serious risks and red flags: [Symptoms requiring urgent care]
• Lifestyle co-therapy: [Nutrition, physical activity, behavioral support expectations]
• Cost/access: [Coverage, prior authorization if discussed]

Response Targets and Stop Rules

Baseline: [Weight] kg; BMI [value]

Early response milestone: [Target weight loss by timeframe on therapeutic dose]

Stop rule: [Discontinuation criteria if target not met or intolerance]

If discontinued: [Alternative therapy, taper if applicable, referral]

Monitoring Plan

Follow-up: [Intervals for tolerability/titration and maintenance]

Track: [Weight, vitals, adverse effects, adherence, mood if relevant]

Labs: [Agent/comorbidity-tailored labs with timing]

Med adjustments: [Plan for diabetes meds, BP meds as weight changes]

Referrals and Orders

Referrals placed: [Nutrition / Behavioral program / Sleep medicine / Bariatric surgery / Specialty consult] (Include only if placed.)

Medications ordered: [List]

Labs ordered: [List]

(If any required safety element cannot be completed, document "Unknown/Not assessed" with follow-up plan. Omit optional sections without data. Use person-first, non-stigmatizing language throughout.)