Behavioral Health & Eating Pattern Screening Note (Obesity Care)

(Use person-first, non-stigmatizing language throughout; e.g., "patient with obesity," "higher weight," "eating concerns." Avoid moralizing terms such as "noncompliant," "failed diet," or "cheating.")

Date/Time: [Encounter date and time]

Provider: [Provider name and credentials]

Setting: [in-person / telehealth]

Indication for Screening: [Baseline evaluation / Pre-medication assessment / Treatment escalation / Patient-reported concerns / Routine follow-up / Other: specify]

Screening Instruments

(Document each administered tool in structured format. If none administered, state rationale. If declined, document with brief context.)

• [Instrument name: PHQ-2 / PHQ-9 / GAD-2 / GAD-7 / SCOFF / BEDS-7 / Other]

  • [Date administered]
  • [Completion mode: self-completed / staff-assisted / interpreter-assisted]
  • [Total score] — [Severity interpretation per standard cut-points]
  • [Critical item flags] (Explicitly document any non-zero self-harm item with item number and response.)
  • [Response validity concerns if applicable]
• (Repeat for each tool administered.)

Chief Concern

[Patient's main concerns about mood, anxiety, or eating patterns in 1–3 lines] (If routine screening without specific concerns, state that explicitly.)

Behavioral Health Symptoms

Depression

• [Duration and course of mood symptoms]
• [Functional impact on work, relationships, health behaviors, self-care]
• [Key symptom anchors: sleep, appetite, anhedonia, concentration]
• [If appetite change present: mood-driven vs medication-related vs linked to eating pattern disturbance]
• [Relevant treatment history]

(If screen negative and patient denies symptoms, document briefly and proceed.)

Anxiety

• [Primary pattern: generalized worry / panic features / social anxiety / health anxiety / other]
• [Somatic symptoms impacting eating or activity]
• [Avoidance behaviors relevant to obesity care]
• [Relevant treatment history]

(If screen negative and patient denies symptoms, document briefly and proceed.)

Eating Patterns & Behaviors

Overview of Current Pattern

• [Meal timing and frequency]
• [Snacking and grazing patterns]
• [Hunger and fullness awareness]
• [Contextual factors: shift work, food access, caregiving demands]

Disordered Eating Features

(When suspected or screener positive, document each as present, absent, or unclear.)

• [Loss-of-control eating: present / absent / unclear] (If present: frequency per week and duration in months.)
• [Eating rapidly: present / absent / unclear]
• [Eating when not physically hungry: present / absent / unclear]
• [Eating alone due to embarrassment: present / absent / unclear]
• [Guilt or distress after eating: present / absent / unclear]
• [Eating past physical discomfort: present / absent / unclear]
• [Compensatory behaviors: purging, laxatives, diuretics, excessive exercise, prolonged fasting, insulin manipulation] (Document each explicitly as present / absent / unclear with frequency if present.)
• [Restrictive patterns: rules, avoidance, caloric restriction, meal skipping]
• [Body image preoccupation / overvaluation of shape and weight]
• [Prior eating disorder diagnosis or treatment]

Medical Risk Indicators

• [Red flags: compensatory behaviors, severe restriction, rapid weight change, syncope, electrolyte-risk behaviors] [present / absent]
• [Medical response if red flags present: same-day evaluation, labs, urgent referral]

(A positive eating disorder screener requires brief clinical interview summary and disposition below.)

[Clinical interview summary and disposition]

Psychosocial Context & Readiness

• [Current stressors: work, family, financial, housing, weight stigma]
• [Coping strategies and social support]
• [Food security: stable / at risk / insecure] (Include if relevant.)
• [Readiness to change: patient-stated health and function goals, confidence and importance ratings if used, barriers and facilitators, change talk elicited]
• [What the patient is motivated to work on now]

Mental Status Exam

• [Appearance and behavior]
• [Speech: rate, volume, fluency]
• [Mood and affect: range, reactivity, congruence]
• [Thought process and content]
• [Insight and judgment]
• [Psychomotor changes or incongruence with reported symptoms] (Include only if present.)

Safety Assessment

(Required if: positive self-harm screening item, disclosure of suicidal thoughts or self-harm, or clinician concern. If no safety concerns and screening negative for self-harm, document "No safety concerns identified" or omit section.)

• [Suicidal ideation: none / passive / active]
• [Plan: present / absent] (Details if present.)
• [Intent: present / absent]
• [Means access: present / absent] (Details if present.)
• [Past attempts or self-harm history]
• [Protective factors]
• [Structured suicide risk assessment performed: yes / no] (If yes, specify risk level and mitigation plan.)
• [Immediate actions taken: safety plan, lethal means counseling, crisis resources, disposition]

Assessment

(Provide integrated clinical interpretation in 1–2 short paragraphs. Distinguish screening results from diagnoses. Address functional impact, key drivers, medical risk flags, and interaction with obesity care plan.)

[Integrated clinical summary]

Problem List: (Order by clinical severity; safety concerns first.)

• [Problems identified]

Plan

(Problem-oriented with specific, actionable steps. Include only sections relevant to this encounter.)

Depression

• [Confirmatory assessment plan]
• [Treatment pathway: therapy referral, medication evaluation, collaborative care]
• [Follow-up timing] (A positive depression screen requires documented follow-up plan; rescreening alone is insufficient.)

Anxiety

• [Diagnostic clarification plan]
• [Evidence-based treatment referral]
• [Follow-up timing]

Eating Pattern / Disordered Eating

• [Diagnostic impression: meets threshold vs subthreshold]
• [Referral pathway: eating-disorder-informed therapy, dietitian with ED competency, specialty program]
• [Nutrition and behavioral guidance] (Emphasize regular meal structure; avoid endorsing extreme restriction; address restriction-binge cycles.)
• [Monitoring plan: weight trends, vitals, labs if indicated, check-in frequency]

Psychosocial Needs

• [Coping skills plan]
• [Referrals: social work, community resources, financial or food assistance]

Readiness and Goals

• [1–3 collaboratively chosen behavioral goals: specific, measurable, function-oriented]
• [Agreed-upon next step before next visit]
• [Contingency plan for setbacks]

Safety

(Include only if safety concerns present.)

• [Safety plan created or reviewed: yes / no]
• [Lethal means counseling performed: yes / no / not applicable]
• [Crisis resources provided]
• [Disposition: outpatient with close follow-up / same-day urgent evaluation / higher level of care]

Referrals & Follow-up

• [Referrals placed with destination, purpose, and urgency]
• [What patient agreed to do before next visit]
• [Follow-up interval and modality]
• [Support person involvement discussed: yes / no] (If yes, specify who and purpose.)