The cholesterol intake form will ask for information that helps the clinician understand whether cholesterol treatment may be safe and appropriate for you.
This may include:
Basic information
Your legal name
Date of birth
Sex assigned at birth
State of residence
Contact details
Cholesterol and heart health
Cholesterol lab results taken within the last 12 months, such as a lipid panel or LDL cholesterol result
Why you are seeking treatment, such as elevated LDL cholesterol or cardiovascular risk reduction
Any history of cardiovascular conditions, such as heart attack, stroke, TIA, or coronary artery disease
Any history of familial hypercholesterolemia, if known
Medication history
Any current or past cholesterol medications, including statins, ezetimibe, or PCSK9 inhibitors
Any history of statin intolerance, if relevant
Your current medications and allergies
Any prior allergic reactions to medication
Whether you have a latex allergy
Other health information
You will also be asked about other health factors that can affect whether treatment is safe or appropriate. This may include questions about things like liver health, kidney health, pregnancy or breastfeeding status, and certain medications or health conditions.
It’s important to answer as accurately as possible. This helps the clinician review your information and decide whether cholesterol treatment may be appropriate.