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Chief Complaint
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Current Weight:
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Goal Weight:
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Current Diet Plan:
• • •
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Behavioral Intervention:
• • •
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Pharmacotherapy:
• • •
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Medication Side effects:
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Weight Loss Since last visit
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Lipo Mic Shot Administered
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Lipo Shot Site
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Treatment Plan
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Semaglutide
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Semaglutide Dosing
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Semaglutide associated recommendations
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Tirzepatide
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Tirzepatide Injection Recommentations
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Provider comments:
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Medication side effects comments:
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General Instructions:
• • •
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General instruction comments:
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Diagnosis:
• • •
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