Healthy Weight Care Assistant
None | Mom | Dad | Bro | Sis | ||
Diabetes | ||||||
Obesity | ||||||
Hypertension | ||||||
High Cholesterol | ||||||
Early Heart Disease | ||||||
Sudden Death |
Yes | No | ||
Polyuria or polydipsia | |||
Snoring or sleep apnea | |||
Headaches | |||
Acne or skin changes | |||
Lower extremity pain | |||
Irregular periods | |||
Fatigue |
2 wk | 1 mo | 3 mo | 6 mo | 12 mo/Next WCV | |
Next visit: |
None | Mom | Dad | Brother | Sister | MGM | MGF | PGM | PGF | |
Diabetes | |||||||||
Obesity | |||||||||
Hypertension | |||||||||
High Cholesterol | |||||||||
Early Heart Disease | |||||||||
Sudden Death |
Yes | No | |
Daily headaches | ||
Tinnitis | ||
Worse lying down | ||
Visual disturbances |
Yes | No | |
Eat out of boredom? | ||
Guilt surrounding eating? | ||
Grazing? | ||
Skipping breakfast? | ||
Eating with the TV? | ||
Eating alone? |
0 | 1 | 2 | 3 | 4 | 5+ | |
Fruits (servings) | ||||||
Vegetables (servings) | ||||||
Sweet drinks/juice (servings) | ||||||
High fat/sugar foods | ||||||
Foods high in calcium/Vit. D | ||||||
Home prepared meals/snacks |
0 | 1 | 2 | 3 | 4 | 5+ | |
Fruits (servings) | ||||||
Vegetables (servings) | ||||||
Sweet drinks/juice (servings) | ||||||
High fat/sugar foods | ||||||
Foods high in calcium/Vit. D | ||||||
Home prepared meals/snacks |
Yes | No | |
Eat out of boredom? | ||
Guilt surrounding eating? | ||
Grazing? | ||
Skipping breakfast? | ||
Eating with the TV? | ||
Eating alone? |
0 | 1 | 2 | 3 | 4 | 5+ | |
Servings of fruits/vegetables per day | ||||||
Hours of screen time per day | ||||||
Hours of physical acivity per day | ||||||
Servings of juice/sweetened beverages per day | ||||||
During an average week, how many days of the week do you eat dinner together as a family? |
< 5 | 6 | 7 | 8 | 9 | 10+ | |
How many servings of fruits and vegetables does your child eat on an average day? | ||||||
How many hours of screen time (computer, TV, inactive video games, tablet, cell phone, etc.) does your child spend watching on an average day? | ||||||
How many servings of juice or sweetened beverages does your child drink on an average day? | ||||||
Hours of sleep, on average | ||||||
During an average week, how many days of the week do you eat dinner together as a family? | ||||||
During an average week, how many days of the week does your child get 1 hour or more of physical activity? |