To Be Completed by My Health Care
Provider
My Health Care Visit
These pages are for your health care provider to fill in.
Now is the time for you and your health care provider to review the information
in this booklet.
Date: ____________________
Height (inches): _____________________
Weight (pounds): _________________________
BMI: ___________________ (Use chart below to find where
height and weight meet.)
The body mass index (BMI) is a measure of body fat based on
height and weight (not just weight alone). A BMI of 25 or higher means you are
overweight or obese and at a higher risk for high blood pressure, heart
disease, stroke, type 2 diabetes, and other conditions. (Note: People who are
muscular tend to have higher BMI scores without necessarily being
overweight.)
Underweight: Less than 18.5
Healthy Weight: 18.5 - 24.9
Overweight: 25 - 29.9
Obese: 30 and above
Other measurements to keep in mind:
Blood pressure: _____________________
Cholesterol level: _____________________
Current Physical Activity Assessment:
- On target
- Recommend changes
Current Nutrition and Eating Habits
Assessment:
- On target
- Recommend changes
Health Care Provider’s Recommendations:
- ___________________________________________________
- ___________________________________________________
- ___________________________________________________
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