Wellness Follow Up Note
Patient name:
Subjective
Appetite:
The patient reports appetite suppression is appropriate / too strong / insufficient. They report that food-related thoughts (“food noise”) are significantly improved / somewhat improved / unchanged / worse compared to baseline.
Side Effects:
The patient reports / denies side effects including mild / moderate / severe (e.g., nausea, abdominal discomfort, constipation, fatigue). The patient states these symptoms are improving / unchanged / worsening over time.
Hydration & Nutrition:
The patient estimates drinking approximately ** oz of water daily. Protein intake is described as adequate most days / inconsistent / likely low. Typical intake consists of three meals daily / two meals daily / small frequent meals / irregular eating. The patient does / does not report difficulty eating enough.
Medication Use & Lifestyle:
The patient reports taking medication as prescribed. Physical activity level is described as minimal / some weekly activity / regular activity. The patient denies / reports sleep concerns impacting appetite or energy.
The patient feels the current dose is appropriate / too low / too high and would prefer to continue the current dose / consider a dose decrease.
Objective
Starting Weight: ** lb.
Current weight: ** lb.
Starting dose: ** mg / start date: **
Dose change: **mg / date
Assessment
The patient is being followed for weight management and metabolic health with ongoing tirzepatide medication management. Clinical response demonstrates adequate appetite suppression, reduction in food noise, appropriate weight trajectory, and acceptable tolerability.
This visit involved ongoing prescription medication management. Dose decisions were individualized based on response, tolerability, and patient-defined goals.
Plan
Tirzepatide will be continued at the current dose, as treatment goals are being met and dose escalation is not indicated at this time.
OR
Tirzepatide dose will be increased to ** mg due to persistent hunger, continued food noise, or inadequate weight response despite adherence in accordance with standard dosing schedule.
OR
Tirzepatide dose will be reduced or held due to side effects or tolerability concerns.
Counseling today included reinforcement of hydration goals, importance of adequate protein intake, and encouragement of sustainable intake without undereating.