Client Progress Note

ATLANTA WEIGHT LOSS & WELLNESS ASSOCIATES

PROGRESS NOTE

DATE * +

TIME *

CLIENT NAME *

DATE OF BIRTH *

ALLERGIES *

HEIGHT *

WEIGHT *

BMI

GOAL WEIGHT *

LMP

NEW OR EXISTING CLIENT *

DIAGNOSIS HX *

B/P, PULSE, TEMP *

PROGRAM START DATE * +

CURRENT MEDICATION *

VISIT NOTE *

DOES CLIENT HAVE ANY CONTRAINDICATIONS? *

NO

YES

DOES CLIENT HAVE HISTORY OF USE? *

NO

YES

HAS CLIENT EDUCATION ON PROGRAM BEEN PROVIDED? *

YES

NO

QUESTIONS & DEMO REQUESTS PROVIDED? *

YES

NO

ENROLLED IN WELLNESS PORTAL? *

YES

NO

Provider Seen *

PROVIDER SIGNATURE *

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