Medical Weight Loss Progress Note printable pdf download

Medical Weight Loss Progress Note

Name: _____________________

Date:_________________

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