General Information
Student Info
Full Name:
*
Birth Date:
*
Please use MM/DD/YYYY
Sex:
*
Male
Female
School Info
School:
*
Zip Code:
*
Grade Level:
*
Please select...
K
1
5
9
Guardian Info
Guardian Name:
*
Guardian Telephone:
*
Health Information
Diabetes
*
Yes
No
Dizziness or chest pain with exercise
*
Yes
No
Heart murmur / High blood pressure
*
Yes
No
Heart problems/ shortness of breath
*
Yes
No
Child wakes during night coughing
*
Yes
No
Diagnosis of asthma
*
Yes
No
Tobacco use
*
Yes
No
Family history of Sudden death before age 50
*
Yes
No
Physical Examination Requirements
Measurements
Height
*
Please enter in inches.
Weight
*
Please enter in lbs.
BMI
*
Systolic Blood Pressure
*
Diastolic Blood Pressure
*
Diabetes Screening
BMI > 85% percentile
*
Yes
No
Please check CDC BMI for age-sex tables.
Family history of diabetes?
*
Yes
No
Ethnic Minority
*
Yes
No
Signs of insulin resistance
*
Yes
No
commons signs of insulin resistance are hypertension, dyslipidemia, polycystic overian syndrome, or acanthosis nigricans