Obesity Medicine Initial Consultation Note

Header

Date/Time: [Encounter date and time]
Encounter Type: [in-person / telehealth]
Clinician: [Clinician name, credentials]
Referral Source / PCP: [Referring clinician and/or primary care clinician]
Data Sources: [Patient interview / EHR documentation / outside records / EHR weight graph / device or wearable data / collateral] (Include only when weight history is reconstructed from multiple sources; specify which sources were used.)

Chief Concern

[Reason for visit] (Single line; optionally include brief patient quote if provided.)

Patient Goals & Priorities

• [Patient-identified priority: health outcome, functional goal, or symptom target]
• [Additional priority] (Include only if provided; list up to 3.)

Constraints/Context: [Budget / time / food access / caregiving responsibilities / transportation / other relevant constraints] (Include only if discussed.)

HPI – Obesity-Focused Evaluation

Weight History

[Narrative description of weight trajectory including onset pattern, progression, timing and triggers of major gains/losses, and weight cycling history]

• Onset pattern: [childhood / adolescence / pregnancy-associated / medication-associated / post-injury / peri-menopause / gradual adult onset / other]
• Highest adult weight: [Weight with units] (Include date/age if known; use "Unknown" if unavailable.)
• Lowest adult weight: [Weight with units] (Include date/age if known.)
• Usual adult weight: [Weight with units or range]
• Weight cycling: [present / absent] – [brief details if present]
• Prior weight-loss approaches:
  • Lifestyle/programs: [Programs tried, duration, response]
  • Medications: [Medication name; duration; best response; adverse effects; reason stopped] (List each medication tried.)
  • Procedures: [Bariatric/metabolic surgery or endoscopic procedure type, year, outcomes, complications] (Include only if applicable.)

Nutrition & Eating Patterns

• Meal timing/frequency: [Brief description]
• Beverage calories: [Sugary drinks, juice, specialty coffee, alcohol]
• Typical day pattern: [Concise outline of meals/snacks]
• Protein/fiber adequacy: [adequate / low / unknown]
• Food access & preparation: [Grocery access, budget, kitchen tools, time to cook]
• Cultural/religious factors: [Relevant dietary practices] (Include only if applicable.)

(If only brief dietary screen was possible, state: "Brief dietary screen only; RD referral placed.")

Physical Activity & Functional Status

• Baseline activity: [Sedentary hours/day, steps/day if known, routine movement]
• Structured exercise: [Type, frequency, duration, intensity]
• Occupational activity: [sedentary / light / moderate / heavy]
• Limitations: [Pain, dyspnea, mobility, balance limitations]
• Preferences: [Preferred activity types/environments]

Sleep & OSA Risk Screen

• Sleep duration/quality: [Hours; insomnia symptoms; awakenings]
• Snoring/witnessed apneas: [yes / no] – [details if yes]
• Daytime sleepiness: [yes / no] – [impact on function; screening tool score if used]
• Schedule: [shift work / regular schedule]
• Prior sleep evaluation: [Sleep study results and date; CPAP use and adherence if applicable] (Include only if applicable.)

(Do not document OSA as diagnosed unless confirmed by polysomnography or home sleep apnea testing.)

Mental Health & Eating Behavior Screen

• Screening tools: [Tool name, score, interpretation] (Include only if performed.)
• Stress & coping: [Brief description]
• Eating behaviors: [Loss-of-control eating / binge episodes / nighttime eating / compensatory behaviors / body image distress] (Document specific behaviors present.)
• Prior eating disorder diagnosis/treatment: [yes / no] – [details if yes]
• Safety: [Suicidality or severe psychiatric symptoms: present / absent] – [actions taken if present]

(If eating disorder concern exists, explicitly document impact on treatment plan and safety measures.)

Contributors & Drivers

• Weight-promoting medications: [Current and historical medications with weight gain potential; include indications]
• Secondary causes suspected: [Specific symptoms/signs prompting evaluation; planned workup] (Include only if clinical suspicion exists.)
• Social determinants: [Food insecurity / housing / transportation / safety for exercise / caregiving demands / access to care] (Include only if relevant.)

Past Medical History

• Cardiometabolic: [HTN, dyslipidemia, prediabetes/T2D with A1c, ASCVD, heart failure]
• Respiratory: [Asthma, OSA with treatment status if confirmed]
• GI/Liver: [GERD, MASLD]
• Musculoskeletal: [OA, back pain, mobility disorders]
• GU/Reproductive: [Incontinence, PCOS, infertility]
• Other: [Additional relevant conditions]

Past Surgical History

• [Bariatric/metabolic procedures: type, year, outcomes, complications] (Include only if applicable.)
• [Other relevant surgeries]

Medications & Allergies

• Current medications: [Medication list with doses] (Flag those with weight-gain potential.)
• Prior anti-obesity medications: [Names; duration; best response; adverse effects; reason discontinued]
• Allergies: [Drug/food allergies with reaction type]

Family History

[Obesity, T2D, premature ASCVD, bariatric surgery, eating disorders, thyroid disease] (Note affected relatives and age of onset if known.)

Social History

• Tobacco: [current / former / never] – [type and quantity if applicable]
• Alcohol: [Frequency, quantity, context]
• Substances: [Type, frequency] (Include only if applicable.)
• Work: [Schedule; shift work if applicable]
• Living situation: [Household composition; support system]
• Food environment: [Food access; cooking capacity]
• Exercise environment: [Access and safety for physical activity]

ROS (Focused)

[Clinically relevant positives and pertinent negatives: fatigue, snoring/apneas, dyspnea, chest pain/palpitations/edema, GERD/abdominal symptoms, joint/back pain, headaches, mood/anxiety, disordered eating behaviors] (Include only findings that inform clinical decisions; avoid exhaustive negative checklists.)

Objective

Vitals & Anthropometrics

• Height: [Height with units]
• Weight: [Weight with units]
• BMI: [Calculated BMI]
• Blood Pressure: [BP]
• Heart Rate: [HR]
• Waist circumference: [Value with units] (Include only if measured.)

Weight change: [Current weight vs prior; percent change from baseline] (Include only if prior weight available for comparison.)

Physical Exam

• General: [Appearance, distress level, mobility]
• Cardiovascular: [Rhythm, murmurs, edema]
• Pulmonary: [Breath sounds, work of breathing]
• Abdomen: [Tenderness, organomegaly]
• Extremities: [Edema, joint findings]
• Skin: [Acanthosis nigricans, intertrigo, striae] (Note pertinent findings.)
• Neck/Thyroid: [Goiter, nodules, neck circumference] (Include only if examined.)
• Affect: [Observed mood and affect]

Labs & Studies

• Reviewed today: [Results with dates: A1c, lipids, CMP/LFTs, TSH, other relevant results]
• Ordered today: [Tests ordered with indication]
• Pending/requested: [Outstanding items and source]

Assessment

Obesity Diagnosis

[Obesity classification: Class I / Class II / Class III] with BMI [value] (Use person-first language.)

Complications staging: [EOSS stage 0–4 or other staging system] (State staging approach used.)

• Active obesity-related complications: [List each with current status/metrics: T2D with A1c, HTN with BP, OSA with treatment status, OA with functional impact, MASLD, dyslipidemia, GERD, other]
• Functional/QOL impact: [Mobility, stamina, pain, daily activities, work capacity]

Drivers Summary

[Brief clinical synthesis of likely contributors to weight gain/difficulty losing weight: medication effects, sleep disruption, pain-limited activity, nutrition access, psychosocial factors]

Plan

Goals & Shared Decision-Making

• Primary goals: [Patient-centered health and functional outcomes]
• Weight target: [Percent weight loss goal or weight maintenance] over [timeframe]
• Success metrics: [How progress will be measured beyond weight: function, labs, symptoms, quality of life]

Lifestyle Therapy

Nutrition: [Dietary approach; cultural considerations; self-monitoring plan; RD referral if indicated]

Physical Activity: [Starting point; progression plan; accommodations for limitations; PT referral if indicated]

Behavioral: [Skills-based strategies; behavioral health referral if indicated; eating disorder safeguards if applicable]

Anti-Obesity Medication Plan

(Include this section only if medication is being initiated or explicitly deferred with documented rationale.)

• Indication: [BMI threshold met; clinical rationale based on complications]
• Contraindications screened: [Relevant contraindications reviewed]
• Medication: [Agent; starting dose; titration schedule; administration instructions]
• Counseling provided: [Expected benefits; common and serious adverse effects; pregnancy/contraception if applicable]
• Monitoring: [Parameters to monitor; follow-up interval]
• Response threshold: [Criteria and timeframe for assessing response; plan if inadequate response]
• Access: [Insurance/PA status; copay assistance if applicable]

(If medication not initiated, document reason: [patient preference / contraindication / eating disorder risk / pregnancy planning / cost-access barrier / other].)

Bariatric Surgery Consideration

(Include only if actively being discussed.)

• Criteria met: [yes / no / uncertain] – [BMI and complication basis]
• Patient interest: [interested / not interested / undecided]
• Plan: [Referral to bariatric surgery program / educational materials provided / defer discussion]

Complication-Specific Plans

(Create a brief entry for each active obesity-related condition being addressed.)

[Condition]: [Current status] – [Treatment plan and interaction with obesity management] – [Next steps]

Orders & Referrals

• Labs: [Tests ordered with indication]
• Referrals: [RD / behavioral health / sleep medicine / bariatric surgery / PT / specialty as indicated]

Follow-Up

• Interval: [Follow-up timeframe]
• Parameters to track: [Weight trend, vitals, medication effects, labs, functional metrics]
• Urgent contact indications: [Red flags relevant to initiated therapies]