High Cholesterol Assessment Form First Name* Last Name* Email* Date MM slash DD slash YYYY Have you had a Fasting Lipid profile drawn at least once over the last 12 months? Yes No Lipid Profile Date MM slash DD slash YYYY Total Cholesterol LDL HDL Triglycerides How many times a week have you been engaging in exercise? 0 1 - 2 3 - 4 5 or more Are you on a low cholesterol diet? Yes No No MD order Have you had any difficulty with chest pain or coronary heart disease? In last 6 months In the last year Never Have you had any of these cardiac procedures? EKG Arteriogram Heart Catheter Angioplasty Coronary Artery Bypass Surgery Other If other, please explainHave you had any changes in your Cholesterol medications? Yes No If yes, please list changesHave you achieved your current Cholesterol goal? Yes No What goal do you want to achieve for your Cholesterol before your next follow-up?** All medical information will be kept confidential in accordance with HIPAA. Thank you for taking the time to complete the questionnaire. We wish you continued success on your Road To Wellness!PhoneThis field is for validation purposes and should be left unchanged. Δ