Supplemental HPI (AWE, Mental Health, Weight Loss)

🗺️ Overview

This guideline is to help us better understand what should be included in the HPI and plan of a Patient encounter regarding the following visits: 

• AWE
• Depression / Anxiety
• Weight loss

🚶 AWE 

• Annual wellness exam - HPI:
  • -- Last AWE date::
  • -- History of lab and abnormal records?:
  • -- Last dental exam:
  • -- Last vision exam:
  • -- Derm:
  • -- Trouble sleeping: 
  • -- Mental Health Hx:
  • -PHQ 9
  • -GAD 7
  • -- DEXA- date done and result (65+)
  • -- Lung cancer screening (50-75 with smoking hx)
    
     
• Annual wellness exam - Plan

General recommendations to address preventative health:

• —Drink at least 64oz of water daily 
• —Regular physical exercise:
• *Aim for at least 30 minutes of moderate activity (e.g., jogging, cycling, swimming) 5 times per week (or at least 150 minutes total per week) or 75 minutes total per week of vigorous activity (e.g., running).
• —A balanced diet rich in whole fruits/vegetables:
• *Aim for at least 2 servings of fruit and 3 servings of veggies per day.
• *An easy rule of thumb is 1/2 plate should contain veggies, 1/4 protein, 1/4 complex carbohydrates.
• *Avoid processed or fried/fatty foods, fast foods, and soda.
• — If you drink, practice moderation of alcohol and caffeine
• —Avoid smoking tobacco
• —Get at least 20 minutes of sunlight daily to increase Vitamin D levels
• —Sleep at least 6-8 hours every night.  
• —Wear sunscreen!  Apply SPF 30 to your face and arms every day to prevent cumulative effects of UV rays
• —Stay up-to-date on your immunizations.  Get your flu / Covid-19 shot every year as well as appropriate CDC vaccinations for your age group.

Recommended screenings to review where applicable: 

• --Cervical Cancer Screening:
• --Breast Cancer Screening:
• --Colon Cancer Screening:
• --Skin Cancer Screening: 
• --Prostate Cancer Screening:
• --Lung Cancer Screening: 
• --Osteoporosis Screening:
  
   

🫥 Depression / Anxiety

• Depression/Anxiety - intake- HPI
  • -- History of depression: 
  • -- History of anxiety: 
  • -- Hospitalizations: 
  • -- Hx of past suicide attempts? 
  • -- Psych Medication hx? 
  • -- Psychotherapy hx?
  • -- SI/HI: 
  • -- Current / past substance use: 
  • – Alcohol use

Social hx:

• -- Living situation (alone, roommates, family): 
• -- Marital Status (single/married/widowed/divorced): 
• -- Employed/Student: 
• -- Exercise: 
• -- Sleep: 
• – Life stressors (past or current or upcoming)
   

• Depression/anxiety - Severe on screening - Plan add-on 

If you have suicidal thoughts, manic episodes, psychosis, or new hallucinations - please seek immediate care at nearest ER or mental health crisis center. 

💉 Weight loss 

• Weight Loss - HPI

Weight

• -- Current weight/BMI? (date):
• -- Goals for weight loss? 
• (Record height, weight, blood pressure, heart rate in vital signs section)- to be done at each appointment*

• – What was your highest adult weight?
• -- What was your lowest adult weight? 
• -- Triggers for weight gain (current or past)?
• -- Support network for weight loss?
• -- Weight loss attempts amount? What was tried? 
• -- Have you tried to lose weight with diet and exercise for at least  six months? 

Food:

• -- What do you eat for breakfast, lunch, and dinner?
• -- What are your food habits? Cravings? 
• – Sodas? Juices? What kind of beverages consume?  
• -- Water intake?
• -- Graze/snacking habits?
• -- Timing of meals? Late meals?
• -- Dietary preferences?
• -- Food allergies?
• -- Fast food? Processed foods? 

Activity:

• -- Exercise regimen ?
• -- Frequency, intensity, duration?
• -- Sports / activities
• -- Equipment access?
• -- Barriers to exercise?
   

• Weight loss - Plan:

Medications for weight loss are most effective when combined with lifestyle changes, including diet, physical activity, and behavioral strategies.

Exercise:

• 5,000–10,000 steps daily
• ≥150–300 minutes/week moderate aerobic activity or 75–150 minutes vigorous activity
• Resistance training ≥4 times/week

Nutrition:

• Emphasize whole foods (vegetables, fruits, lean protein, whole grains, healthy fats)
• Avoid sugary beverages; choose water or unsweetened options
• Limit added sugars and refined carbohydrates

Aim for 7–8 hours of sleep nightly and maintain adequate hydration.