Obesity/Weight Management Medical Nutrition Therapy Note

Date/Time: [Visit date and time]

Patient Name: [Patient full name]

Provider: [Provider name, credentials]

Visit Type: [Initial / Follow-up]

Delivery Mode: [in-person / telehealth]

Referral Source: [Referring clinician and specialty] (Only include if applicable)

Reason for Visit

[Reason for today's visit, including patient's stated priority or concern when available] (Use person-first, non-stigmatizing language throughout.)

Interval Update: [Weight change since last visit with dates; progress on prior goals (met/partial/not met) with brief context; any new barriers or changes in circumstances] (Follow-up visits only. If interval data unavailable, state what is missing and why.)

Nutrition Assessment

Anthropometrics:

• [Current weight, height, BMI with dates and source (measured / reported)]
• [Recent weight trend with ≥2–3 prior weights and dates]
• [Weight history narrative linking timing of changes to drivers when relevant] (If not obtained, state reason and plan.)

Dietary Pattern:

• [Assessment method used (e.g., 24-hour recall, usual intake, food records)]
• [Meal timing, frequency, and typical composition]
• [Key caloric sources: beverages, snacks, restaurant meals, alcohol as applicable]
• [Eating behaviors: hunger/fullness awareness, emotional eating, grazing, meal pacing]
• [Relevant preferences or restrictions: cultural patterns, dietary restrictions, allergies]

(If dietary intake not assessed, document reason and plan.)

Physical Activity: [Current activity type(s), frequency, duration, and functional limitations or barriers]

Psychosocial/Readiness: [Readiness and confidence for change; stress level; sleep quality/duration; social support; food access or security considerations]

Relevant Medical Context: [Weight-related comorbidities; pertinent labs if available; medications affecting weight or appetite] (Include only what is clinically relevant.)

Estimated Needs: [Estimated energy needs with method and inputs; protein target (g/day or g/kg) with rationale; other key targets as applicable] (If not calculated this visit, state why and plan.)

Assessment Summary:

• [Key sources of excess intake or energy imbalance]
• [Primary barriers to behavior change]
• [Patient strengths and supports]
• [Clinical priorities for intervention]

Nutrition Diagnosis

• [PES Statement 1: Problem related to Etiology as evidenced by Signs/Symptoms]
• [PES Statement 2] (If applicable)
• [PES Statement 3] (If applicable)

(Include only diagnoses actively addressed in the plan; signs/symptoms must be measurable for monitoring.)

Nutrition Intervention

SMART Goals:

• Goal 1: [Specific behavior] [frequency] by [target date]; track via [method]
• Goal 2: [Specific behavior] [frequency] by [target date]; track via [method] (If applicable)
• Goal 3: [Specific behavior] [frequency] by [target date]; track via [method] (If applicable)

Nutrition Prescription:

• [Calorie strategy: target intake and/or deficit approach]
• [Protein target and distribution]
• [Meal structure: number and timing of meals/snacks]
• [Key dietary emphases as relevant]

Counseling Provided: [Topics addressed; methods used; materials provided; patient understanding via teach-back if performed]

Barriers & Solutions:

• [Barrier] – [Agreed mitigation strategy]

(Include only barriers identified; use collaborative, non-judgmental phrasing.)

Referrals/Coordination: [Referrals placed and communication with referring provider or care team] (If applicable)

Follow-up Plan: [Recommended follow-up interval and specific agenda items for next visit]

Monitoring Plan

• [Weight trend: target change and timeframe]
• [Dietary adherence metrics: specific behaviors and success criteria]
• [Activity metrics: targets and timeframe]
• [Clinical markers: labs/vitals with target ranges] (If applicable)
• [Patient-reported outcomes: hunger/satiety, energy, sleep, quality of life] (If applicable)

(For follow-up notes: document status of each prior goal [achieved / partial / not achieved / discontinued] with reason, and note any intervention adjustments.)

Provider Signature: [Provider name, credentials, date/time]