BODY MASS INDEX FORM

(To be accomplished by a Licensed Physician)

NAME __________________________________________________________

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ADDRESS
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AGE ______ years old upon application

HEIGHT ______ in cm (barefoot)

WEIGHT ______ in kgs

SEX Male Female

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_ Normal
_ _ Obese I
BMI __ Underweight _
__ _ Obese II
__ Overweight _
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I HEREBY CERTIFY __ that I personally examined
_ the above-named applicant, to
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determine her weight and height measurement.
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_________________ ________________________________
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Date Examined
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_ Name and _Signature of Physician License No.
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Name of Hospital/Clinic:
__ ________________________________
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Contact Number: _ ________________________________
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