Name: ________________________________________
Date: _________________________________________
POINT VALUE
✦ = 3–6 points
✶ = 7–9 points
GRADED
TRIAL
# 1
GRADED
TRIAL
# 2
NOTES
1. ✦ Perform hand hygiene.
2. ✦ Greet and identify the patient;
introduce yourself if you have not
already done so.
3. ✦ If the recent height and weight
measurements are not available,
obtain the patient’s height and
weight.
4. ✶ Insert the patient’s height and
weight into the formula, using
pounds and inches or kilograms
and meters according to facility
policy.
a. Formula for pounds and inches:
BMI = Weight in pounds ÷
(Height in inches × Height in
inches) × 703
b. Example: Wt. 175 lbs; Ht 64
inches
175 ÷ (64 × 64) = 0.0427 × 703
= 30.0 BMI
5. ✦ Record results in the patient’s
record.
GRADING
Points Earned
Points Possible 21 21
Percent Grade (Points Earned/
Points Possible)
PASS: ❑ YES
❑ NO
❑ N/A
❑ YES
❑ NO
❑ N/A
Instructor Sign-O
Instructor: ______________________________________________ Date: _________________________
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