OBESITY - WEIGHT MANAGEMENT PLAN  –   721                     REVIEW – 725   
 <<Practice:Name>>   Phone:  <<Practice:Name>> fax: <<Practice:Name>>	

Patient Details
 <<Patient Demographics:Full Details>>
	GP Details:
 <<Doctor:Full Details>>	Patient agreement for the GP Management Plan proceed
My GP has explained the steps & costs of the GP Management Plan & I agree to proceed.                                                                                                                 Yes            

Where I am referred to other service providers as listed on this GP Management Plan, I consent to my GP sharing  relevant information about myself to that provider. I have advised my GP of any information I wish to be withheld.                                           Yes                                                                        
I Understand that  <<Practice:Name>>  has one health record for patients and that this record is shared by all  <<Practice:Name>> health team providers.         Yes  	

 ASSESSMENT	
Height:            m
Weight :            kg
Body mass index:               kg/m2
Waist circumference:              cm
Co-morbidity assessment (where indicated)
Blood pressure:      
Fasting plasma analysis:     
Triglyceride:     
Cholesterol:     
Insulin:     
Glucose:     
Presence of acanthosis nigricans 
Yes No	Liver function tests
Details:     
Endocrinology tests
Details:     
Orthopaedic problems Yes No
Details:     
Respiratory conditions Yes No
Details:      
Gastrointestinal problems Yes No
Details:     
Reproductive morbidities Yes No
(e.g. menstrual irregularities)
Details:     	Heat intolerance Yes No
Details:      
Excess sweating and intertrigo
Yes No
Details:     
Breathlessness on exertion Yes No
Details:     
Tiredness Yes No
Details :     
Musculoskeletal discomfort Yes No
Details:     	

RISK FACTOR ASSESSMENT	
Weight history of parents and siblings
     
Weight history of individual
     
Life stage pregnant, menopausal, ageing
     	Life events e.g. stress, marriage, giving up sport, quitting smoking
     
Family, work and social environments
     	
Medical conditions and treatments
(including dosage)
     	Ethnicity
     	
LIFESTYLE ASSESSMENT	
Eating breakfast                 Yes No
Organised meals times       Yes No
Always hungry                   Yes No
More than 3 snacks between meals
                                           Yes No
High intake of soft drinks or fruit juice                       
                                           Yes No

More than 2 hours of television viewing and other small-screen entertainment per day    
                                            Yes No	Eating in front of TV         Yes No
Is food used as a reward?   Yes No
Is food used as a comfort? Yes No
Smoker                               Yes No

a)	Type of work, degree of activity
     
b) Current physical activity
     	c) Smoking history
Current          Yes No
No. per day         
Ex-smoker     Yes No
Time quit             

d) Type of food eaten at meals, between meals
Breakfast:      
Dinner:      
Snacks:      	
LEVEL OF INTERVENTION 
Assessment of main causes of overweight: (comment on one or more)	
a) Diet: 

b) Physical activity      

c) Stress       

d) Psychological issues      

e) Other      	Recommend diet diary?
Yes   No   Not at this stage
Recommend pedometer?
Yes   No   Not at this stage

Is specialist assessment required?
Yes   No   Not at this stage
Referral to:      	
MANAGEMENT STRATEGY	GOALS	
 Advice was given to:
Reduce dietary energy intake:                Yes No
Details:      

Increase planned and lifestyle activity   Yes No
Details:      

Decrease sedentary behaviour               Yes No
Details:      

Modify behaviour and habits associated with eating and activity                                                       Yes No
Details:      	a) Short term
     
Weight loss (3–12 months)
Lifestyle modification (decrease energy intake and increase physical activity)

Diet

Weight loss (3–12 months)

Lifestyle modification (decrease energy intake and increase physical activity)
Diet
•Low-fat, reduced-carbohydrate diet
•Very low energy diet (VLED) (commercial, over-the-counter mixture of essential nutrients with defined energy content, usually supplied as a powder to be mixed with water and drunk three times daily)
•Meal replacement program (eg, commercial program that provides preprepared meals)
•Commercial weight loss centre
     
b) Long term
Weight maintenance (lifelong)
Lifestyle modification
Pharmacotherapy (if required)
Bariatric surgery (for obese patients who have failed medical therapy)
     	

Capacity to self manage	
 I have explored readiness for change and barriers for self management
 I have checked that the patient has enough  knowledge, confidence and family support to manage the condition	

Further referrals	
Dietitian      
Nutritionist      
Exercise physiology      
     	

A copy of this plan has been given to the patient.       Yes                                           
Charge item 721                               
Enter recall for review       
Enter recall for new plan      

DATE COMPLETED:  <<Miscellaneous:Date (long)>>	
This section is only to be completed at Review appointment
Review Date        

Enter recall for review       

Claim item 725