OVE R WE I G H T A N D O B E S I T Y I N C H I L D RE N A N D A D O L E S C E N T S

APPENDIX—WEIGHT MANAGEMENT PLAN FOR CHILDREN AND ADOLESCENTS
This plan is intended to be a flexible tool. Some parts may be completed by a practice nurse.
Patient details
Name..................................................................................................
................................................................................................................
DOB............................................ Sex..............................................
Address .............................................................................................
................................................................................................................

2. Co-morbidity assessment
(where indicated)
Psychosocial distress
Is the patient being teased or
bullied about their weight?

Yes

No

Blood pressure
(systolic) .................................... (diastolic) .............................

................................................................................................................
Suburb................................................................................................
State ............................................ Postcode .................................
Phone .................................................................................................
File number .....................................................................................
Date of assessment ....................................................................
Is patient being seen alone or with parent(s)? ..........
................................................................................................................
................................................................................................................

Blood pressure percentile8
% (systolic)............................... % (diastolic) ........................
Fasting plasma analysis
Triglyceride ......................................................................................
Cholesterol......................................................................................
Insulin..................................................................................................
Glucose .............................................................................................
Presence of acanthosis nigricans

Yes

No

Liver function tests
Details ................................................................................................

1. Obesity assessment
Height............................................................................................ m
Weight ..........................................................................................kg

................................................................................................................
Endocrinology tests

Yes

No

Details ................................................................................................
Body mass index ............................................................. kg/m

2

Age............................................... years .........................months
Plot BMI and age on a CDC percentile chart every
3 months6
BMI-for-age percentile...........................................................%

................................................................................................................
Orthopaedic problems

Yes

No

Details ................................................................................................
................................................................................................................
Respiratory conditions

Yes

No

Waist circumference...........................................................cm

Details ................................................................................................

Pubertal stage7 ................................

................................................................................................................

6
7
8

1

2

3

4

5

Electronic versions of these charts are available at http://www.cdc.gov/growthcharts/
Electronic versions of these tables are available at http://www.chw.edu.au.prof/handbook/sect20.htm?print
Electronic versions of these charts are available at
http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm
A guide for general practitioners

....................................................................................................................................................................................... ......................................................... ...................................................................................................... Reproductive morbidities (e......... ................................................................................................................................................ Risk factor relating to food intake and activity levels .......................................................................................................... ......................... Musculoskeletal discomfort Yes No 3..................................................................................................................................................................................... menstrual irregularities) Yes No Medical conditions and treatments (including dosage)........................................................................... Yes No Details ................. .................... Eating in front of TV Yes No Breathlessness on exertion Is food used as a reward? Yes No Is food used as a comfort? Yes No .................................................................................................................................................. Eating as much as parents Yes No Yes No Yes No Details ................................................................................................... Patient Excess sweating & intertrigo More than 2 hours of television viewing and other small-screen entertainment per day Yes No .. A guide for general practitioners More than 2 hours of television viewing and other small-screen entertainment per day ........................................................................................... Family Weight history of parents and siblings ......................................................... ................................................................................................................................... Yes No Details ........................................................................ Eating breakfast Yes No ................................................................................................................................................................................................................................................................................................................................................................................... .......................................... Heat intolerance Yes No Details ................ ............................................................... Details .............................................. Risk factor assessment – weight and medical history ..................................................... Active after school Yes No ...................................................................... 4.................................................................g...................................................... Organised meal times Yes No High intake of soft drinks or fruit juice Yes No Weight history .......................... Ethnicity.................................................................... Always hungry Yes No Tiredness details Any organised weekly physical activity Yes No Able to participate in activity Yes No More than 3 snacks between meals Yes No Details ..................................................................OVE R WE I G H T A N D O B E S I T Y I N C H I L D RE N A N D A D O L E S C E N T S Gastrointestinal problems Yes No Details ........ ..............................................................................................................................................................

................................................................................... Level of intervention Is specialist assessment required? Yes No Involve the family in the process of change Yes No Details ................................................................................................................... Is food used as a comfort? Yes No ........................... ........................................................... Is weight loss required? Yes No .................................... Should adolescent be seen alone? Yes No .................... ............................................................................................................................................................................................................................................................................ ........................................................................................... .......................................................................................... ................................................ Was advice given to: .................................................................................... Is weight maintenance required? Yes No 7................................... Treatment strategy ............................................................................................................................................................................................................................................................................. Modify behaviour and habits associated with eating and activity Yes No Details ........................................................................................................................................................................................................ ............................ .............................................................................................................................................................................. Referral to..... ................ ...............................OVE R WE I G H T A N D O B E S I T Y I N C H I L D RE N A N D A D O L E S C E N T S Eating in front of TV Yes No Increase planned and lifestyle activity Is food used as a reward? Yes No Details .................................................................................................................................................................................................... ......................................................................................................... Details ........................... Reduce dietary energy intake Yes A guide for general practitioners ............................................. ....................................................................................................................................................................................................................................................................................................... No ........................................................................................................................................................................................................ Always hungry Yes No Decrease sedentary behaviour Any organised weekly physical activity Yes No Able to participate in activity Yes No More than 3 snacks between meals Yes No Eating breakfast Yes No Organised meal times Yes No High intake of soft drinks or fruit juice Yes No Yes Yes No No Details .................................. Should parents be seen alone? Yes No .............................................................. Goals ..................................................................................................................................................... 6.......... .......................... ........ ................................................ ....................................................................................................................................................................................................... 5.................................................................

............... ............................................................................................................................................................................................ ............................................................................................................................................................................ Review Problem Goal Treatment/Action .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... ....................................................................... .................................................... ...................................................................................................................................... ................................................................................................................................................................................................................................................................................................ ............................................................... ........................................................................................... ............... A guide for general practitioners .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................OVE R WE I G H T A N D O B E S I T Y I N C H I L D RE N A N D A D O L E S C E N T S 8........................ .............................................

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