Bariatric Medicine Initial Consultation Note

Date/Time: [Date and time of encounter]

Patient Name: [Patient full name]

DOB: [Date of birth]

MRN: [Medical record number]

Visit Type: [in-person / video / telephone]

Referring Provider: [Referring provider name and specialty]

Reason for Consult: [Reason for bariatric/obesity evaluation]

Information Sources: [Sources of history and reliability limitations] (Specify patient, family, outside records, interpreter use, or cognitive limitations if applicable.)

Chief Complaint

[Patient-stated primary reason for seeking care] (Limit to 1–2 lines. Include a brief direct quote if it clarifies goals or expectations.)

History of Present Illness

[Obesity-focused summary narrative] (In 2–4 sentences, summarize the weight concern, trajectory, key contributing factors, and immediate goals.)

Weight History and Prior Treatment

• [Onset pattern and trajectory] (Childhood/adolescence/adulthood; gradual vs rapid; sentinel events such as pregnancy, injury, medication changes, major stressors.)
• [Highest and lowest adult weights and typical adult range] (Include dates or ages when known.)
• [Recent 6–12 month trend and objective data if available]
• [Prior sustained losses and regain patterns] (What worked; factors leading to regain.)
• [Prior treatments] (Structured programs, nutrition counseling, anti-obesity medications with names/duration/response/adverse effects/reason for discontinuation; bariatric procedures with type/date/complications/weight response.)
• [Functional limitations and quality of life impact]

Patient Goals and Preferences

• [Health goals and weight goals]
• [Treatment preferences and constraints] (Medication vs lifestyle-only; cost/coverage; injection aversion; interest in surgery; cultural food patterns; scheduling/logistics.)
• [Patient priority in own words] (Include a concise quote if it meaningfully guides the plan.)

Nutrition and Eating Patterns

• [Typical daily meal and snack timing and composition]
• [Beverage intake] (Water, sugar-sweetened beverages, alcohol quantity and frequency.)
• [High-risk eating behaviors] (Night eating, grazing, loss-of-control eating, binge episodes, fast food frequency.)
• [Protein, fiber, fruit, and vegetable intake patterns]
• [Cooking, food access, and food insecurity risk]
• [Prior diet attempts and sustainability barriers]
• [Tracking tools used] (Apps, logs, devices.)

Physical Activity and Functional Status

• [Baseline activity type, frequency, duration, and intensity] (Include occupational activity and estimated daily steps if known.)
• [Sedentary time and mobility limitations]
• [Exercise contraindications or need for medical clearance]
• Functional status summary: [Single-line summary of functional capacity]

Sleep Assessment

• [Sleep duration, quality, timing consistency, shift work, insomnia symptoms]
• [OSA symptoms and status] (Snoring, witnessed apneas, daytime sleepiness; prior sleep study results; CPAP use and adherence if applicable.)
• (If OSA suspected but not diagnosed, document concern and evaluation plan.)

Behavioral and Psychosocial Factors

• [Mood and anxiety symptoms] (Include screening results if available.)
• [Stress load and relevant trauma history] (Only include if disclosed.)
• [Eating disorder screening results] (Document tool used and positive/negative result.)
• [Substance use affecting weight or appetite] (Tobacco, alcohol, cannabis, other.)
• [Social support and readiness for change]
• [Health literacy or language considerations]
• (If suicidal ideation or severe psychiatric symptoms are present, document risk assessment and actions taken.)

Current Medications

• [Medication list with doses and adherence]
• [Weight-impacting medications identified] (Note agents contributing to weight gain; identify candidates to switch to weight-neutral alternatives.)
• [Supplements and OTC weight-loss products] (Include source and use pattern.)

Obesity-Related Complications

• Known: [Established diagnoses with current control and status] (Cardiometabolic, respiratory, hepatic, GI, musculoskeletal, reproductive, and other relevant conditions.)
• Suspected/Possible: [Symptoms or findings suggesting complications and planned evaluation]
• (If secondary endocrine cause suspected, document clinical suspicion and evaluation plan.)

Past Medical History

• [Active chronic conditions with onset dates when known]
• [Conditions relevant to medication safety] (Seizure disorder, glaucoma, pancreatitis, nephrolithiasis, severe GERD, malabsorption, MTC or MEN2 history.)

Past Surgical History

• [Prior bariatric or metabolic procedures with type and date]
• [Other abdominal or relevant surgeries]

Family History

• [Obesity and diabetes]
• [Premature cardiovascular disease]
• [Relevant cancers] (Include medullary thyroid cancer or MEN2 syndrome if considering GLP-1 agonist therapy.)

Social History

• [Tobacco, alcohol, and other substance use]
• [Occupation and work schedule] (Include shift work.)
• [Living situation and caregiving demands]
• [Food access and transportation barriers]
• [Exercise environment and community resources]

Review of Systems

(Targeted to obesity complications and medication safety. Include only pertinent positives and negatives explicitly mentioned.)

• Cardiovascular: [Chest pain, dyspnea on exertion, lower extremity edema]
• Respiratory/Sleep: [Snoring, witnessed apneas, daytime somnolence]
• GI: [Reflux, abdominal pain, nausea, bowel changes]
• Reproductive: [Pregnancy status or plans, menstrual irregularity]
• Neuropsychiatric: [Headaches, mood symptoms, suicidal ideation]
• Musculoskeletal: [Joint pain, back pain, mobility limitations]
• Skin: [Rash, intertrigo]

(If abbreviated, state: ROS limited to symptoms relevant to obesity complications and medication safety.)

Vital Signs and Anthropometrics

• Height: [Height with units]
• Weight: [Weight with units] (Label as patient-reported if not measured today.)
• BMI: [Calculated BMI]
• Blood pressure: [Blood pressure] (Note appropriate cuff size used.)
• Pulse: [Heart rate]
• Waist circumference: [Waist circumference] (Include when clinically relevant.)

Physical Examination

(Focused on obesity complications and therapy selection. Keep concise; avoid extensive normal findings unrelated to the clinical question.)

• General: [Appearance, distress level, respiratory effort]
• Neck: [Airway features, thyroid if indicated]
• Cardiovascular: [Rate, rhythm, murmurs]
• Pulmonary: [Breath sounds, work of breathing]
• Abdomen: [Tenderness, hepatomegaly, central adiposity distribution]
• Extremities: [Edema]
• Skin: [Acanthosis nigricans, intertrigo, striae]
• Musculoskeletal/Functional: [Gait, sit-to-stand, focal limitations]
• Mental status/Affect: [Brief observation]

Pertinent Data Review

(Summarize key available results with dates. Present problem-oriented highlights rather than full listings.)

• Glycemia: [HbA1c, fasting glucose]
• Lipids: [Total cholesterol, LDL, HDL, triglycerides]
• Metabolic panel: [Electrolytes, liver enzymes, renal function]
• TSH: [Result]
• CBC: [Key findings]
• Relevant imaging/tests: [Liver ultrasound, sleep study, cardiac testing, other]

Baseline labs status: [baseline labs reviewed and sufficient / baseline labs ordered today / baseline labs deferred with reason and follow-up plan]

Assessment

(Problem-oriented format ordered by severity and relevance to treatment planning. Use person-first language throughout.)

Primary Diagnosis: [Obesity diagnosis]

• BMI and classification: [BMI value and obesity class] (Optionally include clinical severity staging with brief rationale.)
• Contributing factors: [Dietary patterns, activity limitations, sleep/circadian factors, medication-associated contributors, psychosocial drivers, possible secondary causes]
• Safety and contraindication flags: [Pregnancy status, cardiovascular disease, pancreatitis or gallbladder history, seizure history, thyroid cancer history, other factors affecting therapy selection] (Omit if none identified.)

[Obesity-related complication 1]

• [Status, current therapy, and control]
• [Relationship to obesity and impact on treatment selection]

[Obesity-related complication 2]

• [Status, current therapy, and control]
• [Relationship to obesity and impact on treatment selection]

(Add additional problems as needed. Do not infer diagnoses from risk factors alone; document concern and evaluation plan instead.)

Plan

(Every problem in the Assessment should have a corresponding plan element. Use specific, measurable goals.)

Lifestyle and Behavioral Intervention

• Nutrition strategy: [Selected approach and rationale] (Specify key targets, portions, meal timing, or pattern. Include cultural preferences and access constraints.)
• Physical activity plan: [Type, starting dose, and progression] (Match to functional status; include aerobic, resistance, and NEAT goals as appropriate.)
• Behavioral strategies: [Self-monitoring, stimulus control, accountability methods]
• Sleep and stress targets: [Goals and interventions] (Include only if applicable.)
• Referrals: [Dietitian / Behavioral health / Physical therapy / Sleep medicine / Structured program / Other] (Include only if placed.)

Pharmacotherapy

• Indication and eligibility: [BMI and complication-based eligibility; options discussed and shared decision rationale]
• Contraindication screening and counseling: [Screening completed; pregnancy considerations and contraception if applicable]
• Selected medication: [Medication name, starting dose, titration plan, common adverse effects and mitigation strategies]
• Monitoring plan: [Weight, symptoms, vitals, labs with intervals]
• Stop/adjust criteria: [Define inadequate response threshold and intolerable adverse effects]

(If not prescribing pharmacotherapy, document reason: patient preference, contraindication, cost/coverage, or clinical priority to address other factors first. If prescribing off-label, document rationale, alternatives discussed, and informed consent.)

Metabolic/Bariatric Surgery Consideration

• Recommendation status: [recommended / under consideration / not indicated at this time] with rationale
• Referral plan: [Referral placed and required pre-referral steps per program requirements] (Include only if referring.)

(If not referring, document reason.)

Obesogenic Medication Optimization

• [Medications identified contributing to weight gain and proposed alternatives]
• [Coordination plan with prescribing providers]
• [Changes made today or rationale for no change]

Diagnostics and Orders

• [Labs ordered with clinical indication]
• [Referrals placed and purpose]
• [Imaging or tests ordered with indication]
• [Preventive care actions relevant to this visit]

Patient Education and Shared Decision-Making

• [Education provided] (Risks and benefits of major options; expectations for weight-loss trajectory; adverse effect counseling.)
• [Patient understanding and agreement or declination]

Follow-up

• Follow-up interval and modality: [Timeframe and visit type]
• Next visit agenda: [Weight review, side effects, labs, device or app data]
• Escalation plan: [Instructions for concerning symptoms]

(Documentation guidance: Use person-first language. For clinically important fields not assessed, explicitly document as unknown or not assessed rather than omitting. Do not infer adherence or responses; record patient report and objective data when available. Omit sections entirely if they contain no relevant information.)