Accompanied by:

y/o male/female, initial Healthy Habits Clinic Intake, referred by Dr. for evaluation and treatment of excess weight.

Problems with weight since:

Changes that occurred in patient’s life around the time that weight started to increase:

Previous Evaluation:

Pt’s perspective of current weight: feels it is a problem.

SMART goals set during Session 1:

Diet:

Breakfast –

Lunch –

Dinner –

Snacks –

Drinks –

Exercise:

Screen Time:

Sleep:

ROS

No fatigue. No sleep problems. No loud snoring.

Noheadaches.

No heat and cold intolerance, No skin/hair/nail changes

Appetite normal. No abdominal pain, nausea, vomiting, constipation or diarrhea. Stools normal.

No polyuria, polydipsia, or nocturia.

No joint pains.

No depression. No concentration problems.

Puberty:

No hirsutism. No acne.

PMH

Birth: BW:

Met early developmental milestones. No early feeding problems.

Other medical diagnoses:

PSH :

Medications:

Allergies: NKDA

Immunizations: UTD for age

Family History

Mother ‘’ tall, menarche at age

Father ‘’ tall, puberty -

MPH = “

Obesity -

Diabetes -

Thyroid disease –

Autoimmune disease –

HTN -

Hyperlipidemia -

CV disease – none < 55

Stroke – none < 55

Cancer –

Social History

School:

Activities:

Cell:

Email:

Exam

BMI = %

Gen: well-appearing, overweight

HEENT: PERRL, fundi normal, nose and OP clear

Thyroid: normal

No cervical LAD

CV: RRR, no murmur

Resp: comfortable, lungs clear

Abd: soft, NT, ND, no HSM

Neuro: DTRs 2+ with normal return

Skin: no acanthosis nigricans, no hirsuitism, no acne, no striae on sides of abdomen

Musculoskeletal: spine straight – no scoliosis noted

Pubertal Assessment:

Peak documented weight:

Current weight:

Goal weight (for BMI=24 at current height):

Ideal body weight at current height:

ASSESSMENT:

  1. Obesity – BMI . Motivation for weight loss is

PLAN:

  1. Labs: CBC, CMP, insulin, fasting glucose, TSH, Ft4, Hgb A1c, lipid panel, 25-OH Vitamin D, FSH/LH, Free and total testosterone panel
  2. Discussed:
  3. BMI and potential health consequences of excess weight
  4. 9-5-2-1-0 plan for healthy lifestyle changes: 9 hours of sleep daily, 5 servings of fruits and/or vegetables daily, less than 2 hours of screen time daily, one hour of physical activity daily, no sweetened beverages
  5. Safe, realistic rate of weight loss 1-2 lbs/week
  6. 75 minutes of group education and problem solving during Healthy Habits Clinic session one. Topics covered included: assessing willingness to change, barriers to change, identifying healthy and less healthy habits, creating SMART goals, and goal setting exercise.
  7. F/u 1 month and with lab results, sooner for problems
  8. SMART goals created at Healthy habits Session 1:

Best contact:

Cell:

Email:

*Enter “BMI” as primary diagnosis code; it will adjust according to percentile in vital signs entry

*Add V65.41: Anticipatory guidance for exercise

*Add V65.43: Anticipatory guidance for nutrition

*Add V65.49: Anticipatory guidance for sleep