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Medically Supervised Weight Loss Documentation - Assessment And Treatment Plan For Obesity Page 2

Thank you for your interest in the University of Michigan Adult Bariatric Surgery Program. In

order to help you and your Primary Care Physician begin your Medically Supervised Weight

Loss Documentation, we have included a form for your use. Please have your physician

complete one form at each monthly visit. Documentation should reflect your weight, diet,

exercise, the lifestyle modifications you have made, and any pharmacotherapy (weight loss

medications). This documentation may vary depending upon your insurance requirements.

Sample of Medically Supervised Weight Loss Documentation:

Diet

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

Notes: Eating 3 meals instead of 1 per day. Limiting intake to 1200 calories. Eating fruits with breakfast. Eating 2

vegetables for lunch. Patient indicated she will join Weight Watchers.

Recommended Dietary Goal(s): Recommend lowfat diet, smaller portions and decrease fast food to reduce__

calorie intake. Goal of 1200 calories per day. Goal is 1-2 pound weight loss per week.

Physical Activity

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

achievable goals.)

Notes: Walking Program set up to increase time as foot is recovering (s/p injection).

Discussed “Moderate Exercise” can include any activity desired including swimming, walking, jogging, biking,__

etc.

Recommended Exercise Goal(s): Recommend daily walking with increasing duration; goal is 60 min/day, as___

tolerated, a total of 5-7 days/week. 60-90 minutes of moderate intensity physical activity 5-7 days/week.

Behavioral Intervention

(Specific strategies and tools for overcoming barriers and improving dietary

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

Notes: Self monitoring, stress management, a log book of food intake and physical activity, problem solving,___

and social support. Eating breakfast to curb hunger and prevent compulsive eating. Having meals ready to___

eat during the week to avoid fast food. Keep log of snacking patterns. Go to Support Group meetings. _

Continues to attend Eating Disorders Therapy.

___

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:

Pharmacotherapy has been considered. She had an allergic reaction to Phen-fen.

Please be as detailed as possible!

Medically Supervised Weight Loss Documentation - Assessment And Treatment Plan For Obesity Page 2