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Metabolic Obesity & Diabetic Clinics

Saleem Memorial Hospital, Lahore

Patient Clinical Assessment Record
A. Demographics & History

Visit Reason & Pregnancy Status

Screening    Gen Checkup    DM    HTN    Obesity    Fatty Liver
Pregnancy (if female):     Yes    No    Unsure
HTN Diabetes Heart Disease Stroke
CKD Liver Disease Viral Hepatitis Other:
Family History:

Premature CAD/MI: Y   N
Diabetes: Y   N 		Lifestyle Factors:

Tobacco:   Pack-years:
Activity (≥150m/wk): Y   N
B. Anthropometry & Vitals
Height (cm) Weight (kg) BMI (kg/m²) Waist (cm)
BP (1st / 2nd / Avg) HR / RR Temp
/ / /
C. Essential Labs (Minimum Required)
Capillary glucose AST / ALT Fasting lipid profile
Urine dipstick / ACR Serum Cholesterol HbA1c
CBC (platelets) Creatinine → eGFR
D, E, F. Risk Assessment & Follow-up
Clinical Risk Scores:
ADA Score:
WHO CVD (10y):
FIB-4 Value:
 Immediate Actions:
Lifestyle Counseling Provided
Medication Adjustment Made
Stop Potential Hepatotoxics
F. Follow-up Plan:

Urgent Referral Required?    Yes    No    |    Specialty:

Routine follow-up scheduled in:   (e.g., 4 weeks)
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