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Patient Check-in
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Check In Information (will show in note if not deleted)
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HPI
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HPI
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Physical Exam
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Height
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Record Height and Weight as Vitals
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Start Weight
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Start BMI
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Current Weight
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Current BMI
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Total pounds lost in the past month
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Total Weight Loss
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% of Total Lost
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Other
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Last Dose
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Last Dose
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Assessment / Diagnosis
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Assessment / Diagnosis
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ROS
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ROS
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Other:
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Treatment Plan
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General Plan
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Medication
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Refill Details
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Lot Number
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Dose #1 (units/week)
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Dose #2 (units/week)
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Dose #3 (units/week)
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Dose #4 (units/week)
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Dose #5 (units/week)
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Dose #6 (units/week)
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Dose #7 (units/week)
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Dose #8 (units/week)
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Dose #9 (units/week)
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Dose #10 (units/week)
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Additional Doses:
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IM Orders
• • •
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Next Appointment Refill Range
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Recommended Nutraceutical Protocols
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Recommended Supplement Protocols
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Insulin Resistance Nutraceutical Support
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Mitochondrial Support - Oxidative Stress
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Diarrhea Nutritional Support
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Constipation Nutritional Support
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Nausea & Gastric Reflux
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Tension - Migraine Headache Nutritional Support
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Other
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Recommended Supplements for Common Side Effects
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Additional Nutraceutical Patient Education
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Additional Pharmaceuticals
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Orders
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Patient Education
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Semaglutide Medication Information
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Tirzepatide Medication Information
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SubQ Injection Instructions
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Aseptic Technique for Drawing up Medications
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Comprehensive Weight Loss Symptom Management Protocols
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Nutritional Recommendations
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GLP1 RA Patient Expectations Education
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Weight Loss Additional Boosters
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Weight Loss Basic Wellness Labs
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Additional Patient Education
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Nervana Contact Information
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Provider
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Provider
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MA / Assistant (Charted by)
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