Child BMI Assessment Form
Please complete the following fields to assess your child's Body Mass Index (BMI) and related wellness factors. All information is kept confidential and used solely for assessment purposes.
Child's Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Other
Height and Weight
*
Rows
Value
Unit
Height
cm/kg
in/lbs
Weight
cm/kg
in/lbs
Physical Activity Level
*
Low
Moderate
High
How would you rate your child's eating habits?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
How many servings of fruits and vegetables does your child eat daily?
0-1 servings
2-3 servings
4 or more servings
How would you rate your child's overall wellness?
1
2
3
4
5
Any additional comments or concerns?
Submit Assessment
Should be Empty: