Free Cardiovascular Lipid Consultation Record, DPH 43015 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 43015 (09/03)

STATE OF WISCONSIN

CARDIOVASCULAR / LIPID CONSULTATION RECORD
Patient: Please complete section A for your health care provider when you go for your office visit. Your physician will complete Section B. If you use a Cardiovascular Wallet Card or other means to keep track of the dates and results of your heart exams and a list of your current medications, take this information with you and show it to your health care provider. Section A. PATIENT INFORMATION Patient Name: Patient Address: Patient Telephone Number: ( ) Date of Birth:

Name of Specialist or Primary Care Provider (PCP): PCP Address: PCP Telephone Number: ( ) PCP Fax Number: ( )

Section B. PHYSICIAN ­ RESULTS OF LIPID TEST Test date: Lipid values normal: Total Cholestrol elevated: LDL Level: HDL Level: Triglycerides: C-Reactive Protein: A1C: Follow-up Recommendations: Requires Repeat Testing / Treatment Requires Treatment Requires Treatment Requires Treatment Requires Treatment

Primary Care Provider Name (Print): SIGNATURE ­ Primary Care Provider: Address: Telephone Number: Fax Number:

Fax or mail this completed form to the patient's specialist(s) or Primary Care Provider.
(Extra copies can be downloaded at: http://www.dhfs.state.wi.us/health/cardiovascular)