Testing of: NHAMCS, NAMCS, 2010 "Itsinourhands" web site, 2010 CFU, 2010 ACS, and 2010 Mailout Materials

Draft 1: Lipoprotein Cholesterol Values Worksheet

Instructions: Record each of the most recent lipoprotein cholesterol values, within the last 12 months, and the date they were reported. If no values are present in the medical record or all of the values are older than 12 months, please check the checkbox.

□ No lab values for past 12 months.

1. Total Cholesterol: ________________mg/dl; date reported: ( _ _ / _ _ / _ _ )

2. HDL: _______________mg/dl; date reported: ( _ _ / _ _ / _ _ )

3. LDL: _______________mg/dl; date reported: ( _ _ / _ _ / _ _ )

4. Triglycerides: _______________mg/dl; date reported: ( _ _ / _ _ / _ _ )

5. Glycohemoglobin A1c (HgbA1C): ________________% of Hb; date reported: ( _ _ / _ _ / _ _ )

6. Fasting blood glucose (FBC): ________________mg/dl; date reported: ( _ _ / _ _ / _ _ )

Draft 2: Lipoprotein Cholesterol and Glucose Values Worksheet

Instructions: Record each of the most recent lab values for the tests listed below, ordered within 12 months of the current visit. Also record the date that they were reported. If no values are present in the medical record or all of the values are 12 months prior to the visit, mark the none box.

□ None

Item number	Lab test	Value	Date reported (mm/dd/yyyy)
1	Total Cholesterol	mg/dl	/ /
2	HDL	mg/dl	/ /
3	LDL	mg/dl	/ /
4	Triglycerides	mg/dl	/ /
5	Glycohemoglobin A1c (HgbA1c)	% of Hb	/ /
6	Fasting blood glucose (FBC)	mg/dl	/ /