Adolescent Medical Weight Management Intake Form

Patient Name: ______ ______, Date of Birth: ______
Patients Preferred Name: ______
Age: ______
Primary Care Physician: ______

______ ______ is a ______ year old patient presenting to the Medical Weight Management Family-Based Pediatric Clinic. 

Grade: ______
Currently lives with: ______ 
Who buys food in the home: ______
Who makes meals in the home: ______
The patient states the following on what they want to get out of this visit. "______"

Current self report weight is: ______
Current self report height is: ______ feet ______ inches
Self report BMI: ______

Patient's weight history is as follows: ***

Patient reports the following answers to food security questions:
Within the past 12 months were you worried your food would run out before you got money to buy more? ______
Within the past 12 months, the food you bought didn't last and you didn't have money to buy more? ______

Diet/Food History:
Food allergies: ______ 
The patient reports the following food behaviors: ______
Frequency of family meals eaten together: ______

Eating Out (times per week)
Fast Food Restaurants: ______ 
Sit-Down Restaurants: ______

Fruits and Vegetables (per day):
Vegetables: ______ 
Fruits: ______

Drink history (servings per day):
Juice: ______ 
Milk: ______
Chocolate Milk: ______
Flavored Milk: ______
Diet Soda: ______
Regular Soda: ______
Coffee: ______
Energy Drinks: ______
Diet Tea: ______
Sweet Tea: ______
Sports Drinks: ______
Water: ______

Screen Use History (hours per day):
TV: ______
Computer for nonschool-related activities: ______
Phone/Tablet: ______

Sleep History:
Weekday bedtime: ______
Weekday waketime: ______
Weekend bedtime: ______
Weekend waketime: ______

Has screens within 30 minutes of bedtime: ______
Has a TV, computer, or phone in the bedroom: ______
Snores: ______
Had evaluation for enlarged tonsils: ______
Feels sleepy during the day: ______

School:
The patient reports missing ______ days of school this year.

Standardized Scales: 

Do you make yourself sick (induce vomiting) because you feel uncomfortably full? ______
Do you worry that you have lost control over how much you eat? ______
Have you recently lost more than 14 lbs in a 3 month period? ______
Do you think you are too fat, even though others say you are too thin? ______
Would you say that food dominates your life? ______

Eat26 Score: ______
Eat26 Behavioral Score: ______

WVU Medicine Pediatric Psychology - Initial Assessment 

PATIENT NAME: ______ ______

PATIENT'S PREFERRED NAME: ______

DATE OF BIRTH: ______

VISIT DATE: @ED@

AGE AT VISIT: ______

TIME IN/OUT: ***

PROCEDURE: ***

Primary Care Physician: ______

Reason for referral: ______ ______ is a ______ year old patient presenting to the Medical Weight Management Pediatric Clinic. They were referred to assess needs for individual and family support for initiating and maintaining healthy lifestyle changes. The patient states the following: "______" as their goals for today's visit. 

The patient and family were seen in conjunction with the multidiscplinary Family Weight Management Team and additional information can be obtained from team clinic notes for today's visit. 

Presenting Concern: 

______ ______ is here today with ***.  ______ provided information via initial intake paperwork and completed assessment measures.  The family provided additional information during today's appointment about their concerns.  

In regards to health status and eating behaviors, ______ reported today that their weight is ______ and height is ______ feet ______ inches.  This calculates to a self-reported BMI of ______.  Via the intake form, ______ reports that ______ buys food for their household. They report that ______ makes meals in the household. 

During today's appointment, the patient and family reported ***. 

Current Diet/Eating Habits: 

The patient reports the following food behaviors: ______
They report that their family eats meals together ______ and eats meals at fast food restaurants ______ times per week and sit-down restaurants ______ times per week. 

In regards to specific diet habits, the patient reports eating ______ servings of vegetables and ______ servings of fruits each day. 

Drink habits are reported to be as follows: 
Juice: ______ 
Milk: ______
Chocolate Milk: ______
Flavored Milk: ______
Diet Soda: ______
Regular Soda: ______
Coffee: ______
Energy Drinks: ______
Diet Tea: ______
Sweet Tea: ______

In regards to food security, the patient reported the following answers:  
Within the past 12 months were you worried your food would run out before you got money to buy more? ______
Within the past 12 months, the food you bought didn't last and you didn't have money to buy more? ______

Social History: 

______ lives with ______.  ***

______ is in ______ at ***.  The report ______ missed school days this year.  They report that school ***

Developmental History: 

Pregnancy:  WNL
Birth weight:  *** lbs, *** oz.
Developmental milestones:

                      Verbal:  WNL
                      Gross motor: WNL
                      Fine motor:  WNL
                      Social:  WNL
                      Adaptive:  WNL
                      Early Intervention (e.g. Birth to Three):  No
Self care;  ______ is currently able to complete age-appropriate self-care tasks.  

Relevant Medical History: 

Current health and medical status: ***
Allergies, including medication allergies: ______
Illness, injuries, chronic conditions, disabilities, physical or sensory limitations: ***
Brain Injury: ***
Current medications: @MEDS@
Medical hospitalization: ***
Surgery: ***
Sleep:  Weekday bedtime: ______
             Weekday waketime: ______
             Weekend bedtime: ______
             Weekend waketime: ______

             Has screens within 30 minutes of bedtime: ______
             Has a TV, computer, or phone in the bedroom: ______
             Snores: ______
             Had evaluation for enlarged tonsils: ______
             Feels sleepy during the day: ______

Screen Use (hours per day):
TV: ______
Computer for nonschool-related activities: ______
Phone/Tablet: ______

Trauma History: ***

Neglect:  Denied 
Physical abuse: Denied
Sexual abuse: Denied
Witness to violence: Denied
Major loss or disruption: Denied
Multiple/out-of-home placement(s): Denied

STANDARDIZED TESTING:

**TESTING CODE=96130 (UNIT/HOUR)

The patient completed several self-report measures as part of today's evaluation.

SCOFF Quesionnaire: The SCOFF Questionnaire is a five item measure, developed to serve as a simple, easy to remember screening tool for eating disorders: a self-report questionnaire used to assess the prevalence of binge eating behavior indicative of an eating disorder in obese patients. A cut-off point of 3 indicates concern for disordered eating. 

The patient's answers on the SCOFF questionnaire are as follows: 

Do you make yourself sick (induce vomiting) because you feel uncomfortably full? ______
Do you worry that you have lost control over how much you eat? ______
Have you recently lost more than 14 lbs in a 3 month period? ______
Do you think you are too fat, even though others say you are too thin? ______
Would you say that food dominates your life? ______

Total score was ***  which indicates ***. 

Eating Attitudes Test - EAT-26: The Eat-26 is a widely used, self-report measure to screen for the attitudes, concerns, and behaviors indicative of disordered eating.  A total score above 20 indicates a high level of concern. Additionally, the EAT-26 asks eating behavior questions, for which any positive endorsement indicates a high level of concern. 

Eat26 Score: ______
Eat26 Behavioral Score: ______

These results indicate: A low/moderate/high concern for disordered eating.  ***

PROMIS Anxiety: The PROMIS anxiety scale is an 8-question self-report measure addressing symptoms of anxiety for children 8+.  Raw scores are converted to scaled scores as follows:

Raw Score       T-score range      T-score interpretation
8-15                          < 50                   Typical/Normative
16-18                       50-55                 Mild
19-27                       55-65                 Moderate
28+                           65+                     Severe

PROMIS anxiety score: ______

PROMIS Depression: The PROMIS depression scale is an 8-question self-report measure addressing symptoms of anxiety for children 8+.  Raw scores are converted to scaled scores as follows:

Raw Score       T-score range      T-score interpretation
8-13                         < 50                   Typical/Normative
14-17                       50-55                 Mild
18-26                       55-65                 Moderate
27+                           65+                    Severe

PROMIS depression score: ______

These results indicate: A low/moderate/high concern for depression.  ***

ASSESSMENT AND MENTAL STATUS:
 

______ was appropriately groomed and dressed for season and occasion. Speech and thought process was goal directed/coherent, and thought content was appropriate.  Mood was euthymic. Affect was consistent with mood.  Eye contact was observed WNL. Attention, concentration, impulse control were observed WNL.  ______ displayed WNL judgment and insight.  No concerns about suicidal and homicidal ideation, plan and intent, hallucinations and delusions were reported today. ______ was oriented to person, place and time and no evidence of a formal thought disorder was observed.

Diagnosis: ***

Recommendations/Plan: ***