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SUBJECTIVE
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Week #
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Labs drawn
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Maintenance
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Comments on Maintenance
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Reason for visit
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Comments on Reason
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Eating Plan
• • •
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Comments on Eating Plan
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Adherence to Plan
• • •
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Comments on adherence
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Fluids
• • •
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Bouillon
• • •
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New Meds
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Comments on New Meds
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Exercise
• • •
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Comments on Exercise
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Activity
• • •
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Comments on Activity
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Sleep
• • •
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Comments on Sleep
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Mood
• • •
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Comments on Mood
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Stress:
• • •
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Comments on Stress
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Weight Management Meds
• • •
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Comments on Wt Management meds
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Bowels
• • •
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Comments on Bowels
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Bloating/Gas
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Comments on Bloating/Gas
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Abdominal Pain
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Comments on Abdominal Pain
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Dizzy/Light-headed
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Comments on Dizziness/Light-headedness
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Headache
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Comments on Headache
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Fatigue
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Comments on Fatigue
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Other
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Visit Checklist
• • •
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OBJECTIVE
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General WNL
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General Abnormal
• • •
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General Comments
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HEENT WNL
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HEENT Abnormal
• • •
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HEENT Comments
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Skin WNL
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Skin Lesion
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Skin Comments
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Neck WNL
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Neck Abnormal
• • •
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Neck Comments
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Cardiovascular WNL
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Cardiovascular Abnormal
• • •
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Cardiovascular Comments
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Lungs WNL
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Lungs Abnormal
• • •
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Lungs Comments
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Abdomen WNL
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Abdomen Abnormal
• • •
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Abdomen Comments
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MSK WNL
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MSK Abnormal
• • •
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MSK Comments
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|
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Breasts WNL
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Breasts Abnormal
• • •
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Breasts Comments
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Neuro WNL
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Neuro Abnormal
• • •
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Neuro Comments
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Extremities WNL
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Extrem Abnormal
• • •
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Extrem Comments
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Weight change
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Duration of weight change
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Labs
• • •
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Comments on Labs
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ASSESSMENT
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Assessments
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Assessment
• • •
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Assessment comments
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Obesity
• • •
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PLAN
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Overall Treatment Plan
• • •
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Treatment plan comments
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Dietary
• • •
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Dietary comments
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Exercise
• • •
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Exercise comments
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Education
• • •
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Education comments
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Medication prescribed:
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Prescription method for med
• • •
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Medication Refill
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Prescription method for refill
• • •
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Labs
• • •
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Comments on Labs
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Other tests
• • •
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Follow-up needs
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MD F/U
• • •
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Weight check
• • •
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Time
• • •
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Comments on Time
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Counseling/Care Coordination
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Clinical Summary
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IBT
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