Pediatric Body Mass Index (Bmi) Form For Medi-Cal Members
ADVERTISEMENT
1701 Gateway Blvd. Suite 400 South San Francisco, CA 94080
TEL 650-616-0050 FAX 650-829-2009
Pediatric Body Mass Index (BMI) Form for Medi-Cal Members
(Use for members 0–20 years of age)
Please complete this form to receive your $25 incentive.
FAX a copy to HPSM at 650-829-2009. BILL HPSM with CPT code 99411 and modifier WT.
Patient Name: ______________________________
HPSM Member ID #: ___________________________________________
DOB: ______________
Sex: ¨ M ¨ F
Date of Measurement: _____________________
INSTRUCTIONS for Members 2–20 yrs.
INSTRUCTIONS for Members <2 yrs.
1. Use the BMI wheel / calculator to determine BMI.
1. Plot length by weight on the growth chart.
2. Plot the BMI number on the BMI growth chart to determine BMI %.
2. Write percentile below.
3. Write the height, weight, BMI and percentile below and mark the category where the
percentile falls.
Check off BMI Category
Weight for Length % ______
Height (in): _______
□
< 5% Underweight
□
Weight (lbs): _______
5%–84% Healthy weight
□
85%–94% Overweight
BMI _______
□
95%–98% Obese
BMI % _______
□
≥ 99% Severe Obesity
Please assess and counsel your patient about the following behavioral risk factors:
• Sedentary time (TV, computer, video games): _________ hours per day
• Physical activity: ________ hours circle: per day OR per week
(e.g. active play, sports, P.E., walking/biking/skate boarding to and from school)
□
□
□
□
□
□
• Servings of fruits and vegetables per day:
<1
1
2
3
4
≥ 5
(note: “servings” are self-defined, the patient’s regular portion of this food.) Do not include potato chips or French fries.
• Servings of sugar-sweetened beverages: _____ servings per day
(e.g. Coke, Sunny Delight, Hawaiian punch, Hi-C, Gatorade, Snapple, energy drinks, iced tea, etc.) Do not include diet drinks.
• Breastfeeding duration, if known: ____________ months
□
□
• Provided patient with nutrition counseling, educational materials, anticipatory guidance, or referral:
Yes or
No
□
□
• Provided patient with counseling, educational materials, anticipatory guidance, or referral for physical activity:
Yes or
No
Here are some useful evidence-based messages for all children regardless of weight: (please check items you discussed)
□
□
Decrease screen time to 2 hours/day or fewer
Limit eating out, especially of fast food
□
□
Limit sugar-sweetened beverages
Eat a healthy breakfast every day
□
□
Eat at least 5 servings of fruits and vegetables
Remove television from children’s bedrooms
□
□
Be physically active 1 hour or more daily
Limit portion sizes
□
Have regular family meals
_____________________________________________
____________________
___________________________________
Provider Signature
Date
Provider Name (Print/Stamp)
HPSM v.2.1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical