Healthy Lifestyle Improvements: Fit Kids FAMILY REGISTRATION

Healthy Lifestyle Improvements: Fit Kids
LAB REPORT FORM
(Complete with your child’s information.)
Child’s Name: ______________________ Age: _____ Date of Birth: ________ Sex: M F
Parent/Guardian Name: ___________________________________________________
Street Address: _________________________________________________________
City: ______________________________ State: _______ Zip Code: _______________
Phone: (Home) ________________ (Work) ________________ (Cell) _______________
Physician Name, Address & Phone
CURRENT ASSESSMENT (within past month):
Data Date of Measurement
Blood Pressure
Height
Weight
BMI
BMI %
LAB REPORT (within 3 months):
Total Cholesterol
LDL
HDL
Fasting Insulin
Fasting Glucose
Physician Signature: ____________________________________________________
Date: ________________________________________________________________
Please return completed form to:
Beth Passehl, MS
Fit Kids Program Coordinator
1655 Tullie Circle
Atlanta, GA 30329
Fax: 404-785-7243
Data Date of Measurement