Your/Your Child’s Weight Management Visit –
What to Expect, What to Ask
Your Name: Your Relationship to the Child:
Are there specific concerns you want to discuss today? □ No □ Yes
Have there been any major changes in your family lately?
□ None □ Move □ Job Change □ Separation □ Divorce □ Death in the family
□ Other? Describe:
□ New pet
General Health Information. Since Your Last Visit:
Have you (or your child) had any major illness and/or hospitalizations?
Have you or anyone in your family (or your child’s relatives) developed new any medical problems?
Are there any changes to your (or your child’s) medications?
Are your (or your child’s) immunizations (includes flu and pneumonia vaccines) current?
Do you or any adults who are around you (or your child) smoke (includes inside or outside the house)?
Yes
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□
□
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No
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□
□
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Unsure
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Have you or your child been in seen in the Emergency Room or hospitalized in the last 6 months for Weight management
related problems?
□ No □ Yes 1-2 times □ Yes 3-4 times □ Yes 5-6 times □ Yes more than 6 times
Do you or your child currently include any of the following in your daily diet?
□ Fish □ Chicken □ Green leafy vegetables □ Low fat cheese/milk □ Fresh fruit □ Vegetables □ Fruit
Is your (or your child’s) body mass index greater than 30? □ No □ Yes □ I don’t know
In the last 3 months have you talked with your (or your child’s) doctor or health provider concerning any of the following
symptoms? □ Severe headaches □ Confusion □ Chest pain □ Blurred vision □ Nausea and vomiting
□ Pounding in chest, neck □ Feeling very tired □ Dizziness
Have you received referrals, tests, tests results and or other needed care promptly? □ No □ Yes
Do you or your child have any of the following symptoms currently?
□ Unusual thirst □ Increased urination □ Dizziness □ Blurred vision □ Frequent infections □ Slow healing
□ Extreme hunger □ Feeling very tired □ Unusual weight loss
Would you like to get more information on any of the topics below?
Medications/Treatments Symptoms Health Promotion Nutrition
• Checking/Monitoring • Signs of High Blood • Smoking Cessation • Healthy diet
blood pressure Pressure
• [National Quitline: 1-800- • Calorie intake
• Lab tests to check/ • Signs of Diabetes QUITNOW (784-8669)]
• Healthy snacks
monitor Cholesterol
• Signs of High Cholesterol • High Cholesterol
• Decrease fat
and Blood Sugar
prevention
• Risk factors for High intake
• Weight loss
Cholesterol • High Blood Pressure
• Weight
• Herbal remedies prevention
• Risk factors for High Blood management
Pressure • Diabetes prevention
• Alcohol intake
• Exercise routine
• When to call doctor
This is not a self-diagnosis tool or a treatment plan. Please consult your doctor and share this with your doctor at your next visit.
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