Cholesterol Screening Cholesterol Date * (MM/DD/YYYY) Patient * DOB * (MM/DD/YYYY) 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 Email my copy here Confirm Email my copy here Email and email verification If you are human, leave this field blank. Submit
