AMRS ID Number:

Family Name:

Given Name:

Middle Name:

Gender: ... Male Female

Date Of Birth:

Age & gender Female: ... <35 years >35 years Male: ... <40 years >40 years

Weight (kg): HEIGHT (CM): BMI: kg/m² ≥ 25kg/m²? Yes No

Waist circumference (cm) : Men ≥94cm? Women ≥80cm? Yes No

Location Name:*

Provider ID:

Encounter Date:*