Medical Weight Loss Progress Note printable pdf download

Medical Weight Loss Progress Note

Name: _________________________

Date:_________________

DOB ______________ Weight:_________ Blood pressure:_________

Change In Weight Since Last Visit:________ BMI:_________________

Diagnosis: __________________________________________________

____________________________________________________________

Diet Plan:

Include Notes From Diet Plan with PCP notes

Weight Watchers

L A Weight Loss

Jenny Craig

Eat Right

Other: (specify)____________________

Compliant with Diet Plan?

YES / NO

Weight loss medications: ________________________________________

Total Daily Caloric Intake:_______________

Physical Activity/ Exercise Plan:

Gym_____x’s wk

Walking/Running___x’s wk

Aerobics____x’s wk

Exercise Videos____x’s wk

Inability To Perform- Comments:________________________________

Recommended Modifications:____________________________________

Behavior Modification:

Dietitian Consult

Date:__________

Group Counseling

Date:__________

Individual Counseling Date:__________

Recommended Modifications:___________________________________________

Comments: (progress or lack of progress)

Provider Signature: _______________________ Date:_______

Typed or Printed Name: ________________________________

Medical Weight Loss Progress Note