Looking for a Weight Loss Tracking Sheets? Download it for free!

Medically Supervised Weight Loss Documentation - Assessment And Treatment Plan For Obesity

Medically Supervised Weight Loss Documentation

Assessment and Treatment Plan for Obesity

This form must be completed at each office visit for the duration specified by your insurance company.

Patient Name:

Date of Visit:

Registration Number: _____________________________

Date of Birth: _____________________________________

Weight:

lbs.

Height (first visit):

in.

BMI:

Blood Pressure:

Pulse:

Diet

(Prescribed caloric restriction, review of dietary intake and recommendations).

Notes:

Recommended Dietary Goal(s):

Physical Activity

(Physical exercise program appropriate for age and physical condition. Recommend

achievable goals.)

Notes:

Recommended Exercise Goal(s):

Behavioral Intervention

(Specific strategies and tools for overcoming barriers and improving dietary

compliance, for example log books, support groups, stress management, social support).

Notes:

Pharmacotherapy

(This must be addressed and documented. List FDA approved weight loss drugs and

strength or indicate that patient is unable to tolerate or refuses pharmacotherapy).

Notes:

Physician Name (Please Print)

Physician Signature

Medically Supervised Weight Loss Documentation - Assessment And Treatment Plan For Obesity