MY HEALTH CARE VISIT
Date: ____________________
This page is for your health care provider to fill in. Now
is the time for you and your health care provider to review this information
together.
BMI (body mass index) is an estimate of body fat. BMI is calculated from your height and weight.
|
Weight (lbs.): |
_________ |
BMI-for-age percentile |
What it means |
95th
percentile |
Overweight |
85th to
95th percentile |
Risk of Overweight |
5th to 84th
percentile |
Healthy Weight |
5th percentile |
Underweight |
|
Height (inches): |
_________ |
BMI: |
_________ |
Age: |
_________ |
BMI percentile for age and sex:* |
_________
|
Growth comment: |
___________________________________
___________________________________
|
* See http://www.cdc.gov/nchs/data/nhanes/growthcharts/set3/chart%2016.pdf
Current Physical Activity Level Assessment:
- On target
- Recommend change
|
Current Nutrition and Eating Habits Assessment:
- On target
- Recommend change
|
Health Care Providers Recommendations:
1._____________________________________
2._____________________________________
3._____________________________________ |