Patient Assessment Sheet (BMI > 27)

Goal: Understand your concerns about weight and overall health.

Personal Details
Anthropometry & Physical Exam
BMI
Height: cmWeight: kg
BMI:IBW: kg
Waist Circ.: cmHip Circ.: cm
Wt/Height Ratio:WHR:
Neck Circ.: cm
BCA
Visceral Fat:[VF < 9]
Fat Mass %:[M:10-22% / F:18-30%]
Lean Mass %:
Skel. Muscle %:[M:33-36% / F:26-30%]
BMR: kcal
Body Water %:
BP: / mmHg   Pulse: bpm
Medical & Family History
ConditionPatientMotherFatherSiblingsGrandparents
Hypertension (High BP)
Type 2 Diabetes
Pre-diabetic / Insulin Resistance
High Cholesterol / Dyslipidemia
Obstructive Sleep Apnea
Cardiovascular Disease
NAFLD / Fatty Liver
Osteoarthritis / Knee Pain
PCOS (if female)
Hypothyroidism
Depression / Anxiety
Gout / High Uric Acid
Others:
Signs and Symptoms
SymptomYNSymptomYN
Shortness of breathStress incontinence
Breathlessness on lying downLimitations in mobility
Dyspnea on exertionLimitations in daily activities
Chest pain / tightnessLeg swelling (edema)
PalpitationsAbdominal pain / bloating
Fainting / passing outHeartburn / GERD
Trouble sleeping / SnoringDepression / low mood
Fatigue / low energyAnxiety / nervousness
Increased / frequent urinationInternalized weight bias (IWB)
Bleeding / bruising historyStigmatization (felt)
Joint pain / stiffness(Women) Regular cycles
Excessive sweatingSkin infections / rashes
IWB: believing negative stereotypes about SELF.   STIGMATIZATION: FELT negative attitude / discrimination
Lifestyle & Diet
Total Calories:
Carbs:
Protein:
Oil:
UPF/Junk:
Sugar drinks:
Fruits/Veg:
Water:
MEALS:
Bfast: Lunch: Dinner:
hrs hrs/day hrs
Surgical & Medication History
Surgery?
Obesity surgery?
Highest weight: kg
Lowest (adult): kg
Past attempts:
Medications:
Smoking:
Alcohol:
Red Flags (Last Month)
Sleep: Early-morning waking or fragmented sleep
Muscular: Jaw clenching or neck/shoulder tension
GI: Acid reflux, nervous stomach, appetite changes
Cognitive: Brain fog, irritability, decision fatigue
Metabolic: Weight plateau or late-night cravings
Your Story
Which feels most true right now?
I want to start my healthy weight-loss journey
Lost weight but can't maintain it
Lost weight but regained, can't lose again
Can't lose weight despite diet + exercise
Lost weight, can't follow the same diet anymore
Medical issues make weight loss difficult
Physical Activity & Sleep
Exercise Type:
Frequency: Duration:
Since:
Occupation:
Sleep
Duration: hrs Bed: Wake:
Falling asleep (>30min)
Frequent night waking
Early-morning waking (3-4AM)
Snoring / gasping
Daytime sleepiness
Quality:
Patient Assessment — Page 1 of 2  |  BMI > 27

Patient Assessment Sheet (BMI > 27) — Page 2

Psychological Assessment & Management Plan

Psychological & Stress Evaluation
How often? (1=Never / 5=Always)
I eat when stressed:
Food for comfort/relief:
Guilty after eating:
Struggle to feel full:
Worry about weight/shape:
Lack motivation/energy:
Binge / lose control:
Eating Phenotypes:
PSS-4 (Perceived Stress)
(0=Never / 4=Very Often)
Unable to control important things?
Confident handling problems?
Things going your way?
Difficulties piling up?
Score: / 16 (>6 mod, >9 high)
Anti-Obesity Medications (AOM)
Ever taken AOM?
Consider AOM now?
Surgery referral?
Readiness & Goals
Stages of Change
Pre-contemplation – Not considering change
Contemplation – Thinking (within 6mo)
Preparation – Planning action soon
Action – Making changes now
Maintenance – Sustained >6 months
Weight target: kg in mo
Primary goal:
Barriers:
Motivation (1-10):
Lab Investigations
HbA1c: %Fasting Glu: mg/dL
T. Chol: mg/dLLDL: mg/dL
HDL: mg/dLTG: mg/dL
TSH: μIU/mLVit D: ng/mL
Crtn: mg/dLALT/AST: U/L
Uric Acid: mg/dLCortisol: μg/dL
Clinical Assessment Summary
Obesity Stage:
Stage 0
Stage 1
Stage 2
Key Findings
Metabolic Risk:
Co-morbidities:
Recommendations & Plan
Dietary:
Exercise:
Lifestyle:
Medication / AOM:
Referrals:
Follow-up Plan
Next visit:
Frequency:
Mode:
Targets for next visit:
Additional Notes:
Clinician:
Signature: Date:
Patient Assessment — Page 2 of 2  |  BMI > 27  |  Clinician's Copy