Semaglutide: History & Physical

Semaglutide: History & Physical

Please complete the following form during the client's initial Semaglutide visit.
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
CC: ____________________________________________________

HPI: ____________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________
Past Medical History:
Rx Meds:
Vitamins/Supplements/Over the Counter Meds:
FH:
Surgical History:
Social History:
ROS:
Vital Signs
BP:      P:      RR:
Temp:      Pulse Ox:
Ht:      inches
Wt:      lbs
BMI:
Physical Exam
Circumference-
Abd:      cm @ umbilicus
Hip:      cm @       below iliac crest
Thigh:     cm @      above patella
Arm:      cm @      above olecranon
ASSESSMENT:

1) ________________________________________________________

2) ________________________________________________________

3) ________________________________________________________

DIAGNOSIS:

1) ________________________________________________________

2) ________________________________________________________

3) ________________________________________________________

PLAN:

1) ________________________________________________________

2) ________________________________________________________
Business Affiliate Name
Provider Signature

Clear
Date

MonthDayYear
Date
Physician Initials:

________________
Should be Empty:

Semaglutide: History & Physical

Vital Signs

Physical Exam