Cholesterol Screening Cholesterol Cholesterol 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 Panels9/8/23 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 If you are human, leave this field blank. Submit
