Supervised Lifestyle and Integrative Medicine (SLIM) Intake Visit 

Demographics:
Medical Record #: @MRN@ 
Date: @FDATE@ 
Patient Name: @NAME@ 
DOB: @DOB@
Age: @AGE@
Sex: @SEX@
Location: {Patient location:22468}

Evaluator(s): 
@NAME@ was evaluated by me today.  
Clinic Location:  @DEPARTMENTNAME@

Pre-visit planning reviewing the last office visit, labs, imaging and care everywhere when applicable was *** minutes
Intra-visit was *** minutes and included updating the relevant history, performing a video or in-person physical exam as appropriate, creating a treatment plan and used shared decision making with the patient. 
Post-visit was *** minutes that encompassed note completion, placing of orders, updating patient instructions and coordination of care.

Total duration of encounter spent in the above activities, excluding separately reportable services/procedures: *** minutes

@NAME@ is a @AGE@ @GENDERID@ with Chief complaint of: @CHIEFCOMPLAINTN@

HPI:***
Patient presents to discuss elevated BMI, and related sequelae including***
Reason for joining the program

ROS: per HPI 


OBJECTIVE:
The patient is a WDWN @SEX@ in NAD, non-toxic appearance
@VS@
PAVS: @FLOW(26069)@ minutes/week

General Appearance: healthy, alert, no distress, pleasant affect, cooperative, generally non-toxic appearance
CV: No cyanosis. Grossly no distended neck veins 
Pulm: Non-tachypneic, no accessory muscle use, able to speak full sentences.

Relevant labs and EKG reviewed with patient: 
@THISVISIT@


A/P:***
See Patient instructions, meds, orders and diagnoses below for detailed plan. 
Patient was counseled to obtain fasting labs
Patient engaged in goal setting 
Patient was deemed eligible for the SLIM program

@DIAGNOSESORDERS@

@PATINSTR@

***PROVIDER SIGNATURE***

Supervised Lifestyle and Integrative Medicine (SLIM) Follow Up Visit 

Demographics:
Medical Record #: @MRN@
Date: @FDATE@
Patient Name: @NAME@
DOB: @DOB@
Age: @AGE@
Sex: @SEX@
Location: {Patient Location:22496}
Patient seen Status: {Patient seen or not:34782}
 
Evaluator(s):
@NAME@ was evaluated by me today.  
Clinic Location: @DEPARTMENTNAME@

Pre-visit planning reviewing the last office visit, labs, imaging and care everywhere when applicable was *** minutes
Intra-visit was *** minutes and included updating the relevant history, performing a video-based physical exam as appropriate, creating a treatment plan and used shared decision making with the patient. 
Post-visit was *** minutes that encompassed note completion, placing of orders, updating patient instructions and coordination of care.

Total duration of encounter spent in the above activities, excluding separately reportable services/procedures: *** minutes


Subjective: 
SUBJECTIVE:
@NAME@ is a @AGE@ @SEX@ with chief complaint of: @CHIEFCOMPLAINTN@

Patient is presenting for follow up CIM visit as a follow up visit for SLIM program for obesity and comorbidities of ***

Interim progress: ***

Patient had/did not have*** their labs done and they were reviewed with the patient. 
Lab findings: ***

Patient's 24hr diet recall: ***

NHANES nutrition assessment: ***

Patient's questionnaires from intake visit: ***
Self-efficacy to manage chronic disease 
PSS
STOP-BANG
Mindfulness 
ACEs 

ROS: per HPI 


OBJECTIVE:
The patient is a WDWN @SEX@ in NAD, non-toxic appearance
@VS@

General Appearance: healthy, alert, no distress, pleasant affect, cooperative, generally non-toxic appearance
CV: No cyanosis. Grossly no distended neck veins 
Pulm: Non-tachypneic, no accessory muscle use, able to speak full sentences.

Relevant labs and EKG: 
@THISVISIT@


Assessment and Plan: 
See Patient instructions, meds, orders and diagnoses below for detailed plan. 
@NAME@ is a @AGE@ @SEX@ with excess weight and lifestyle and obesity related comorbidities of:

Patient presenting to Supervised Lifestyle and Integrative Medicine (SLIM) Program to address these conditions with lifestyle medicine and pharmacotherapy

I engaged in counseling with patient, providing individualized lifestyle medicine and medical weight management plan. 

Meds: I discussed medication options with patient including bupropion/naltrexone, phentermine/topirmate, and GLP-1 agonists. We discussed risks and benefits of the medications. Patient opts to take/opts NOT to take *** medication at this time. Patient is on a structured diet and exercise plan and meets criteria for anti-obesity medication with BMI>27 with comorbidity. 

@DIAGNOSESORDERS@

Nutrition goals discussed. See individualized plan in patient instructions 
Labs, if completed were reviewed with the patient***

@PATINSTR@

Patient to follow up for group visit program. 

***PROVIDER SIGNATURE***

UCSD SLIM Lifestyle Weight Loss Program Progress Note	

Date: @TD@

Medical Record #: @MRN@ 
Date: @FDATE@ 
Patient Name: @NAME@ 
DOB: @DOB@
Age: @AGE@
Sex: @SEX@

HPI: 

Goal/progress from previous week: ***

Review of Systems: 
General: Denies significant fatigue, fevers
Cardiovascular: Denies dizziness or lightheadedness
Respiratory: Denies shortness of breath
Gastrointestinal: Denies abdominal pain, dyspepsia, diarrhea or constipation
Neurologic: Denies headaches

PMH
@PROB@
@PMH@

PSH
@PSH@??

Family Hx 
@FAMHX@?

Social Hx
@SOC@ 

Meds
@MEDSCURRENT@ 

Allergies
@ALLERGY@


Objective 
Vitals:

Most recent:
@revfsr[195@

Previous:
@vitalsmultipleenc@

Labs:
@thisvisit@


A/P: @NAME@ is a @AGE@ @SEX@ who attends 90 minute sessions, in a virtual group setting, which include the following:

• Nutrition education, including individualized dietary support and planning
• Guidance on regular physical activity tailored to each patient's individual needs
• Lifestyle education including mindfulness, stress management and sleep hygiene
• Supportive Counseling
• Behavior modification based on accepted behavior therapy strategies, including:
- Motivational techniques 
- Self monitoring
- Stimulus control
- Social support
- Planning
- Problem solving
- Cognitive restructuring
- Self efficacy and sustainability
• Community resources provided

Issues identified: None 

@FNAME@ is doing well, without major symptoms or complaints.

Med adjustment as follows: None

Goal for next week: ***

@DIAGNOSESORDERS@

***PROVIDER SIGNATURE***

Age of onset: ***
Weight range: ***
Life event triggers: (illness, medication, pregnancy) ***
Past weight loss attempts:
Specific diets/programs: ***
Medications for weight loss: ***
Medically supervised programs: ***
Meal replacement programs: ***
What worked best? ***
What didn't work? ***
Any diagnosis of eating disorders? ***
Any night eating:***
	
Nutrition: 
Eating triggers: people, places, activities, emotions (stress, boredom, anger) ***
Cooks at home? ***
Restaurant frequency: ***
Fast food frequency: ***
Reasons for eating out: (convenience, work, leisure, enjoyment) ***

Physical Activity:
@PAVS@
Favorite physical activities ***
Barriers to physical activity ***

Birth control/desire to become pregnant ***
Social support ***

Sleep
Hours:
Quality:

Mental Health
Current/previous struggles: ***

UCSD SLIM Lifestyle Weight Loss Program H&P

Date: @TD@

Patient Name: @NAME@ 
DOB: @DOB@
Age: @AGE@
Sex: @SEX@

PCP: Dr. @PCP@

HPI: 

Patient goal for program/motivation: 

Weight:
Age of onset: ***
Weight range: ***
Life event triggers: (illness, medication, pregnancy) ***
Past weight loss attempts:
Specific diets/programs: ***
Medications for weight loss: ***
Medically supervised programs: ***
Meal replacement programs: ***
What worked best? ***
What didn't work? ***
Any diagnosis of eating disorders? ***
	
Nutrition: 
Eating triggers: people, places, activities, emotions (stress, boredom, anger) ***
Cooks at home? ***
Restaurant frequency: ***
Fast food frequency: ***
Reasons for eating out: (convenience, work, leisure, enjoyment) ***

Physical Activity:
@PAVS@
Favorite physical activities ***
Barriers to physical activity ***

Birth control/desire to become pregnant ***
Social support ***

Sleep
Hours:
Quality:

Mental Health
Current/previous struggles: ***

@phq9table@
@gad7@

ROS
General: Denies lack of energy, daytime sleepiness
HEENT: Denies snoring
Cardiac: Denies chest pain, palpitations, leg swelling
Pulmonary: Denies dyspnea on exertion, sleep apnea
GI: Denies abdominal pain, reflux, constipation, diarrhea
GU: Denies ***erectile dysfunction, decreased libido, ***irregular menses
MSK: Denies joint pains
Endocrine: Denies polyuria, polydipsia, fatigue, cold intolerance
Neurologic: Denies headaches, neuropathy
Skin: Denies ***hirsutism, acne, rash
Mental health: Denies depression, anxiety

PMH
@PROB@
@PMH@

PSH
@PSH@??

Family Hx 
@FAMHX@?

Social Hx
@SOC@ 

Meds
@MEDSCURRENT@ 

Allergies
@ALLERGY@

Objective
@VS@
@BMI@	
@waistc@	

Neck circumference: ***
Waist circumference: ***
Body composition: ***
% body fat
VAT

Physical Exam: 
HEENT: No facial plethora, hirsutism, conjunctival injection
Neck: No enlarged thyroid, masses, nodules, posterior cervical fat pad
Lungs: CTAB, no wheezing
Heart: Normal rate, regular rhythm, no murmurs 
Abdomen: No tenderness, masses, ascites, hernias, striae
Neurologic: Normal spontaneous movement of all limbs
Extremities: No edema, lymphedema, lipedema, myalgias, muscle wasting, + pulses
Skin: No acanthosis nigricans, acne, skin tags, xanthomas
Psych: Pleasant, cooperative, answering all questions

Labs: 
@THISVISIT@

A/P: @NAME@ is a @AGE@ @SEX@ presenting for initial visit to determine eligibility for shared medical appointment program. @CAPHE@ meets the inclusion criteria for the SLIM weight management program. 

***

Patient presenting for obesity management along with related comorbidities of:***

Mental health referral:***

Behavioral/coaching support:***

Sleep referral: ****

Meds: ***

Counseling performed. Goals:***

Weight loss goal (5-10%): *** 
Adjusted Body Weight: ***
https://globalrph.com/medcalcs/adjusted-body-weight-ajbw-and-ideal-body-weight-ibw-calc/

Patient to have fasting labs done before follow up video visit 

@FNAME@ will attend regular 90-minute group sessions, in a virtual group setting, which include the following:

• Nutrition education, including individualized dietary support and planning
• Guidance on regular physical activity tailored to each patient's individual needs
• Lifestyle education including mindfulness, stress management and sleep hygiene
• Supportive Counseling
• Behavior modification based on accepted behavior therapy strategies, including:
-Motivational techniques 
-Self monitoring
-Stimulus control
-Social support
-Planning
-Problem solving
-Cognitive restructuring
-Self efficacy and sustainability
•Community resources provided


@DIAGNOSESORDERS@

@PATIENTINSTRUCTIONS@

Pre-visit planning: Reviewing the questionnaires including weight management intake, MSPSS, PHQ, GAD, PROMIS-10, labs, imaging and care everywhere when applicable was *** minutes.

I spent more than *** minutes face to face with the patient in care coordination and counseling on diet, lifestyle, sleep, exercise, mental health and risks and benefits of treatments.

Post visit: *** minutes encompassed note completion, placing of orders, updating patient instructions and coordination of care.

Total duration of encounter spent in the above activities, excluding separately reportable services/procedures: *** minutes.

HEENT: No facial plethora, hirsutism, conjunctival injection
Neck: No enlarged thyroid, masses, nodules, posterior cervical fat pad
Lungs: CTAB, no wheezing
Heart: Normal rate, regular rhythm, no murmurs 
Abdomen: No tenderness, masses, ascites, hernias, striae
Neurologic: Normal spontaneous movement of all limbs
Extremities: No edema, lymphedema, lipedema, myalgias, muscle wasting, + pulses
Skin: No acanthosis nigricans, acne, skin tags, xanthomas
Psych: Pleasant, cooperative, answering all questions

# Excess Weight
- Pt is on ***
- Doing well on the medication 
- Continue behavioral weight loss counseling, group support, diet and exercise counseling toward a hypocaloric diet in shared medical appointment setting

# HTN 
- Continue behavioral interventions, dietary and exercise changes, as well as counseling and shared appointment visits with goal of DASH consistent diet 
- Meds per PCP

# Prediabetes 
- Continue work toward low glycemic and high fiber diet 

# T2DM 
- Pt is doing well 
- Pt's blood sugars are controlled/not controlled***
- Last a1c***
- Next a1c/BG to track improvement from pt counseling:***

# Elevated Lp(a) 
- Continue healthy lifestyle behaviors 
- Lp(a) does not typically change with lifestyle behaviors but it can. We will monitor after patient has completed her program and if remains elevated send to preventive cardiology 

# HLD 
- Continue behavioral change and counseling/group support during shared medical appointment with goal toward high fiber diet 
- Statin as per PCP

# Metabolic syndrome 
- Stable/improving 
- Continue high fiber low glycemic diet 

# OSA 
- Continue lifestyle change. Meds if needed. 
- Continue to monitor. Mild OSA can improve with weight loss 
- CPAP as per pulmonary

# NAFLD/NASH 
- Pt to continue behavioral change interventions and group support in shared medical appointments, as well as patient counseling on low glycemic, high fiber diet
- Monitor LFTs. 
- Last check: ***. 
- Recheck in ***

# Mood issues
- Patient counseled on basic behavioral health techniques 
- Continue group support via shared medical appointments 
- Therapy referral as needed and meds per PCP/psych 

# PCOS 
- Stable 
- Continue behavioral change counseling and group support with goal of high fiber, low glycemic diet

Fullplateliving.org - Describes how to incorporate a high fiber diet 
1) Sign up for an account
2) Click on "member library" in upper right hand corner once you sign in 
3) Go to weight loss course and start 
4) There is also a Facebook community if that is of help to you as well as other resources: https://www.facebook.com/FullPlateLiving/

Guidelines & Tips
1) Intact grains only - no sugar or flour 
Actual whole grains: 
Farro 
Barley
Wheat berries
Amaranth 
Kasha/buckwheat
Steel cut oatmeal 
Freekeh
Quinoa 
Brown rice
Only sprouted bread like ezekiel brand
 
2) 8-10 servings of fruits and vegetables daily 

3) Psyllium - increase by 1 tsp per day each week until 6 tsp per day or whatever you can tolerate (8oz of water per 1 tsp of psyllium) 

4) To help you feel full - Start at 45g of protein per day - lean protein, non-fat dairy, legumes (prefer). Increase protein by adding protein sources. Eg) peanut butter powder, edamame, tofu, tempeh, non-fat cottage cheese, non-fat greek yogurt or icelandic skyr, and lean meats, beans (particularly lentils with the bran around them have fewer calories), nuts and seeds (seeds have fewer calories). Increase until you feel satiated. 

5) Have a soup and a salad daily to provide volume 

Very Low Calorie Kickstart Procedure:
 
------------------------------
1. Make each day 830-850 kcal using guidelines below and follow for 3 weeks:
- Take a multi vitamin daily
- Coffee with benefiber x 2 per day 
- Use meal replacement daily (Orgain Meal Replacement, Pure protein, Functional formularies, Kate farms, Equate, Slim Fast)
- Make Chia fresca with 32oz water with 1-2tsp psyllium and 2 tsp potato starch (added to cold water). Can add hibiscus tea, lemon or other tea to flavor. Also may add some sugar alcohol (xylitol, erythritol) to flavor. A couple of teaspoons of honey if needed. Recipe below:

Chia Fresca Recipe: 
2 tbsp chia seeds 
Boil in water 
Add jamaica to it (hibiscus flower petals can get in hispanic market) 
Cool in the refrigerator 
Add 1 tsp starch (after it is cold)
Add 2 tsp honey 
If you can tolerate, add 1 tsp of psyllium (to the cold tea) 
Consider increasing the psyllium until you get to 2 tbsp per day. Increase psyllium by 1 tsp per week. 

- Then have a large salad and large soup as evening meal 
------------------------------
2. Then as a maintenance, follow for 5 days per month (can be distributed as one week per month or one day per week) 
 ------------------------------
3. Food re-introduction: Use the 14 day ACLM Jumpstart 
 ------------------------------
4. While doing this, go to Fullplateliving.org - describes how to incorporate a high fiber diet. 

- Sign up for an account
- Click on "Member Library" in upper right hand corner once you sign in 
- Go to weight loss course and start watching the videos 
- There is also a facebook community if that is of help to you as well as other resources: https://www.facebook.com/FullPlateLiving/

1) Intact grains only - no sugar or flour 
Actual whole grains: 
Farro 
Barley
Wheat berries
Amaranth 
Kasha/buckwheat
Steel cut oatmeal 
Freekeh
Quinoa 
Brown rice
Only sprouted bread like ezekiel brand 

2) 8-10 servings of fruits and vegetables daily 

3) Psyllium - increase by 1 tsp per day each week until 6 tsp per day or whatever you can tolerate (8oz of water per 1 tsp of psyllium) 

4) 45g of protein per day - lean protein, non-fat dairy, legumes (prefer) 

- Self-Compassion: The Proven Power of Being Kind to Yourself by Kristin Neff
- Feeling Good - The New Mood Therapy by David Burns 
- 10 Days to Self Esteem by David Burns 
- The Body Is Not an Apology: The Power of Radical Self-Love by Sonya Renee Taylor 

Mindfulness-Based Stress Reduction Resources:
- UCSD Center for Mindfulness 
- Apps: 2meditate, Headspace, Insight timer, Buddhify, 10% Happier
- Online MBSR Class (free): https://palousemindfulness.com
- Emindfulness (https://life.emindful.com)
- Sounds True (http://www.soundstrue.com/store/mbsr-course)

Please consider therapy, and in particular, biofeedback. 
We can refer you if needed!

Pre-prepared Meals:

Plant-Based: 
- Daily Harvest https://www.daily-harvest.com/ 
Frozen ready made meals. They send you frozen bowls to heat in the microwave (add your choice of liquid), flatbreads, smoothies (just add your choice of milk) and ice creams. 
- Mama Sezz https://www.mamasezz.com/
Meal delivery service, very heart healthy meals. Good for people who have a history of heart disease or high blood pressure. They have a Diabetes Reversal Program. 
- Splendid Spoon https://splendidspoon.com/
Ready made meals, typically soups, bowls delivered to you. I do not recommend smoothies or noodle bowls. A little higher in sodium but much better than fast food and there is a lot of variety. Easy way to get your vegetables 
- Thistle https://www.thistle.co/
Plant based meals, typically salads, but other options as well, delivered to you. Really interesting, and tasty, dressings. 
- Methodology https://www.gomethodology.com/
Ready made meals delivered to you. Very flexible - they have vegan, keto, paleo, mediterranean, low fat and pescetarian options. For gluten free folks, paleo option is a good fit. Have programs for gut health. 
- Sakara https://www.sakara.com/
Plant Based meals delivered to you. A little pricier. Programs focused on gut health.
- Nutrition for Longevity https://nutritionforlongevity.com/
Deliver plant based meals from local farms. 
- Mosaic https://www.mosaicfoods.com/
Whole Food Plant Based Frozen meals delivered to you. Both individual and family meal options available. 
- Vegin' Out: Healthy Whole Food Plant Based Meals (veginout.com)
Whole foods plant based meals delivered to your home 
- Plantable: Plant-based meals, health coaching, and support

Not Plant-only: 
- Trifecta Nutrition: Delivered Meals | Fresh Meal Plan (https://www.trifectanutrition.com/)

Keto/Low Carb (all have plant-based low carb options): 
- Factor 75: factor75.com
- Fresh 'n Lean: https://www.freshnlean.com/

Paleo: 
- Petes Paleo: https://www.petespaleo.com/