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Telemedicine Consent
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Visit Info
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Pre-Op Number
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Type of Visit
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Recommendations
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Education for Patient Provided at the Visit
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Weight/Height Bariatric Measurements
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Weight
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Height
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BMI
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BSA (calculated)
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IBW (lbs) - Calculated
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IBW (lbs) - Based on BMI 25
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Today's Excess Weight (lbs)
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Today's Excess Weight (lbs) BMI 25
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Initial excess weight
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Personal Reasons
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Obesity-related medical problem
• • •
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Obesity related medical problem COMMENTS
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Weight Loss Efforts
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Vitamins/Minerals
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Food allergies
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Alcohol
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Tobacco
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Drugs
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Exercise
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Minutes of exercise per session
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Nutrition Intervention & Education Provided
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Progress
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Patient understanding appears
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Patient adherence is expected as
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Progress Comments
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Plan
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FOLLOW UP PLAN
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PCP
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Smoking Cessation Counseling
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Nutrition Time Spent
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Allison's Signature
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