My Bright Future: Physical Activity and Healthy Eating

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TO BE COMPLETED BY MY HEALTH CARE PROVIDER

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
95^th percentile	Overweight
85^th to 95^th percentile	Risk of Overweight
5^th to 84^th percentile	Healthy Weight
5^th 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 Provider’s Recommendations:

1._____________________________________

2._____________________________________

3._____________________________________

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"Julie is not only my best friend - she’s my exercise buddy! On days when I just don’t feel like exercising, she pumps me up and motivates me to get going because she knows physical activity keeps us strong and healthy. And I do the same for her. Some days we go running together. Other days we go out dancing!"
Vanessa
El Centro, CA