Cholesterol Screening | Storybook Pediatrics

Cholesterol

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Date *

(MM/DD/YYYY)

Patient *

DOB *

(MM/DD/YYYY)

Questions

1. Is this child adopted? *

Yes

No

2. Are the medical records available or medical history known for parents or grandparents? *

Yes

No

3. Has either parent or any grandparents experience any of the following? Check all that apply.

Mother or grandmother under the age of 65 who has had a heart attack, stroke, or blocked arteries

Father or grandfather under the age of 55 who has had a heart attack, stroke, or blocked arteries

Total cholesterol over 240mg/dl

4. Is this child overweight? *

Yes

No

5. If your child has risk factors for high cholesterol or early heart disease, are you interested in screening labs? *

Yes

No

Special Note

FAQ Sheet: Lipid Panels
9/8/23

The AAP recommends lipid screening beginning at age 8 years for the following populations:

*Obese children: defined as a BMI greater than the 95% for age (E66.9)

*Children whose parents or grandparents have had a heart attack, stroke, or blocked arteries younger than 65 in women and 55 in men (Z82.41, Z82.49)

*Children who have a parent or grandparent with a total cholesterol of 240 mg/dl or higher (Z83.42)

*Children whose family history is unknown. (Z84.89)

(Source: healthychildren.org 8/20/2020)

We at Storybook Pediatrics also recommend this screening.

We do recommend that you check with your insurance company prior to this lab draw to ensure that they will cover these labs.
The codes for the diagnoses are listed above. You can provide your insurance company with the appropriate codes

If your child is obese, we recommend the following labs:

Lipid panel

Hemoglobin A1C

AST/ ALT

If there is relevant family history or family history is unknown, we recommend the following:

Lipid panel

Alternatively, if you wish to do so, we can send the labs as self pay. The self pay prices are listed below for Lab Corp. Our phlebotomist can draw these labs and send them to the lab.

Lipid Panel: $102.90

Hemoglobin A1C: $69.30

ALT/AST: $77.70