Healthy Weight Counseling Visit Note (Pediatrics)

Visit Details

• Date: [date of visit]
• Patient: [name, age, sex]
• Visit Type: [initial / follow-up]; [in-person / telehealth]
• Reason for Visit: [referral source or concern prompting visit]
• Participants: [patient and caregivers present; interpreter if used]

Subjective

Chief Concern: [chief concern in patient/caregiver words; brief visit agenda] (Use person-first, non-stigmatizing language throughout.)

Weight/Growth History: [onset/trajectory of weight pattern; prior strategies tried and response; family understanding/perception] (For follow-up visits, include interval changes, progress on prior goals, and barriers encountered.)

Lifestyle History: [nutrition pattern including meals, snacks, beverages, eating context; physical activity type and frequency; sedentary and screen time; sleep schedule, duration, and quality] (Attribute information to patient vs. caregiver; note if estimates. Include relevant psychosocial factors such as mood, body image, weight-based teasing, or disordered eating behaviors. If eating disorder red flags present, document risk assessment and modified counseling approach.)

Relevant Medical/Family History: [conditions affecting weight or activity tolerance; weight-affecting medications; family history of type 2 diabetes, dyslipidemia, early cardiovascular disease, fatty liver] (Include only pertinent positives.)

Objective

Anthropometrics: [height; weight; BMI; BMI percentile] (Include severity metric for severe obesity if available. Note if patient-reported or telehealth-obtained with limitations.)

Growth/BMI Trend: [synthesis of trajectory from prior data points with dates and percentiles] (Required. State explicitly if prior data unavailable.)

Vitals: [blood pressure with cuff size if abnormal; other vitals as relevant]

Exam: [problem-focused findings relevant to comorbidities: general appearance, skin findings, tonsillar size if sleep concerns, hepatomegaly if indicated, MSK/gait limitations] (Omit exhaustive normal findings.)

Data: [labs reviewed with dates and pertinent results; screening tools with scores and interpretation] (Summarize key findings only.)

Assessment

Weight Status: [meets criteria for underweight / healthy weight / overweight / obesity / severe obesity] based on BMI [value] at [percentile]. (Use person-first phrasing. Note if new or ongoing diagnosis.)

Comorbidity Evaluation: [relevant findings or risk status including BP category, lipid/glucose/liver screening status, sleep-disordered breathing concern, mental health concerns, MSK limitations; secondary causes not suspected or concern for secondary cause with rationale] (Organize by clinical priority. Use "concern for" or "risk for" when not yet confirmed.)

Plan

Counseling Approach: [family-centered approach used; family priorities; key education delivered] (Maintain health-focused, non-appearance framing.)

Lifestyle Recommendations: [1-3 targeted, realistic recommendations across nutrition, activity, and/or sleep tailored to family constraints] (Include referrals with indication if applicable: dietitian, intensive behavioral program, behavioral health.)

Labs/Screening: [ordered with rationale / not indicated / deferred with reason / declined] (Use applicable option only.)

SMART Goals: [1-3 specific behavioral goals with frequency, responsible party, and tracking method] (If family not ready, document readiness stage and harm-reduction or information-only approach used.)

Follow-Up: [timeframe] (Specify what will be reassessed: growth trend, goal progress, labs, BP. Include criteria for earlier return if applicable.)