Patient Assessment Sheet (BMI > 27)

Goal: We would like to understand your concerns about your weight and overall health.

Personal Details
Anthropometry and Physical Examination
Body Mass Index (BMI)
Formula: BMI = Weight (kg) / Height (m²)
  • Height: (cm)    Weight: (kg)
  • BMI:
  • Waist Circumference:
  • Waist/Height Ratio:
  • Neck circumference:
Body Composition Analysis (BCA)
  • Visceral Fat: [VF < 9]
  • Fat Mass%: [M:10–22%F: 18–30%]
  • Lean Mass %:
  • Skel Muscle Mass%: [M:33–36% F: 26–30%]
Lifestyle History
Diet History
  • Total Calories (Approx. kcal):
  • Carbohydrates:
  • Vegetarian Protein:
     Non-Veg:
  • Seed Oil Use:
  • UPF/Junk/Fried/Food items:
MEAL TIME:
Breakfast Afternoon Dinner
SLEEP TIME: SITTING TIME:
Medical & Family History
Condition Patient Mother Father Siblings Grand parents
Hypertension (High BP)
Type 2 Diabetes
Pre-diabetic
High Cholesterol
Obstructive Sleep Apnea
Cardiovascular Disease
NAFLD / Fatty Liver
Osteoarthritis/Knee Pain
PCOS (if female)
Hypothyroidism
Others (specify):
Weight journey:
Medication history
Any diabetic medication:
Signs and Symptoms
SymptomYesNo SymptomYesNo
Shortness of breath Stress incontinence
Breathlessness on lying down Limitations in mobility
Dyspnea on exertion Limitations in daily activities
Chest pain Leg swelling
Palpitations Abdominal pain
Fainting / passing out Heartburn
Trouble sleeping / Snoring Depression and stress
Fatigue Anxiety
Increased frequent urination Internalized weight bias (IWB)
Bleeding history Stigmatization
Joint pain (For women) Regular cycles
IWB: believing negative stereotypes about SELF.
STIGMATIZATION: FELT negative attitude, discrimination because of their weight
Psychological & Stress Evaluation
How often do you experience the following? (1 = Never / 5 = Always)
• I eat when stressed:
• I turn to food for comfort or emotional relief:
• I feel guilty after eating:
• I struggle to feel full or satisfied after meals:
• I worry about my weight or body shape:
• I lack motivation or energy:
Eating Phenotypes:
Rapid Screen: PSS-4 (Perceived Stress Scale)
(0 = Never, 1 = Almost Never, 2 = Sometimes, 3 = Fairly Often, 4 = Very Often)
• Unable to control important things?
• Confident in your ability to handle problems?
• That things were going your way?
• That difficulties were piling up too high?
Total Score: / 16
(Score >6: Moderate stress | Score >9: High stress)
Somatic & Lifestyle "Red Flags" (Last Month)
Sleep: Early-morning waking (3–4 AM) or fragmented sleep.
Muscular: Jaw clenching (bruxism) or chronic neck/shoulder tension.
GI: Acid reflux, "nervous stomach," or appetite changes.
Cognitive: Decision fatigue, irritability, or "brain fog."
Metabolic: Unexplained weight plateau or late-night cravings
Let's Start With Your Story
(Which statement feels most true for you right now?)
I want to start my healthy weight-loss journey.
I lost weight but can't maintain it even after changing my habits.
I lost weight but regained it and now can't lose again.
I'm not able to lose weight despite dieting and exercise.
I lost weight, but can't follow the same diet anymore.
Have you ever taken Anti-obesity medications? Would you want your doctor to consider AOM?
Notes
Obesity Stage
STAGE 0
STAGE 1
STAGE 2