Medical Weight Management Follow-Up Note (Lifestyle and Pharmacotherapy, In-Person or Telehealth)

(Use person-first, non-stigmatizing language throughout. Omit optional elements rather than marking N/A. Do not infer objective data.)

Date of Service: [Date]

Clinician: [Clinician name, credentials]

Encounter Type: Follow-up, Medical Weight Management

Modality: [In-person / Telehealth]

(Include the following telehealth block only if Modality is Telehealth.)

• Telehealth modality: [audio-video / audio-only]
• Patient location: [City, State]
• Provider location: [Location]
• Participants present: [Names and roles]
• Consent: [Statement confirming patient agreed to telehealth and understood limitations]
• Exam limitations: [Limitations due to modality]

Chief Concern

[Reason for today's visit with patient's primary focus] (Single line; include a brief patient quote only if clinically meaningful.)

Subjective

Interval Summary: [Last visit date]; [Current weight] ([Change since last visit: absolute and percent]); [Net change from program baseline if tracked]. [Intercurrent events]. [Overall adherence and engagement trends.]

Lifestyle and Behavioral Treatment: (Brief narrative or bullets focused on what was attempted, what happened, and key barriers.)

• Nutrition: [Current approach and self-monitoring]
• Physical activity: [Type, frequency, duration]
• Behavioral factors: [Sleep, stress, supports, barriers as relevant]

Anti-obesity Medications: (Include only if patient is on pharmacotherapy. Document for each agent.)

• [Medication name, dose, duration]; [Adherence]; [Clinical response: appetite, satiety, cravings]; [Side effects with severity and mitigation attempted]; [Access or logistics issues]
• (When initiating, stopping, or significantly changing medication, note that options, risks, benefits, and patient preferences were discussed.)

Objective

• Vitals: [Weight, BMI, blood pressure, heart rate as relevant]; [Height (label as historical if carried forward)]. (For telehealth, label patient-reported values with source and timing. If a value was not obtained, state so with reason.)
• Exam: [Focused findings relevant to obesity complications and medication safety]. (For telehealth, limit to observational assessment and acknowledge modality limitations.)
• Data Reviewed: [Labs, imaging, or home monitoring logs with dates] (Include only decision-relevant findings.)

Assessment

Obesity/Overweight: [Severity or classification]; [Response category: responding / partial response / plateau / not responding] with supporting data; [Contributing factors identified]

Weight-related comorbidities: [List with brief status updates] (Include only conditions addressed today.)

Plan

Lifestyle:

• [1–2 targeted nutrition changes]
• [1–2 activity goals]
• [Behavioral skill focus or barrier mitigation steps]

Medication: (Include only if applicable.)

• [Continue / Titrate / Switch / Stop] [medication name and dose]; [Rationale]
• [Monitoring plan with timeframe]
• [Stopping or reevaluation criteria]
• (Include pregnancy precautions and contraception counseling when clinically indicated.)

Comorbidities: [Treatment changes or coordination plans for weight-related conditions]

Follow-up: [Next visit timing]; [Preferred modality]; [Pre-visit requirements]

Safety-netting: [Return precautions and how to contact clinic for urgent concerns]

Total clinician time: [Minutes] (Include only if documenting time for billing.)