Your/Your Child’s High Cholesterol Visit –
What to Expect, What to Ask
Your Name: Your Relationship to the Child:
Are there specific concerns you want to discuss today? □ No □ Yes
Have there been any major changes in your family lately?
□ None □ Move □ Job Change □ Separation □ Divorce □ Death in the family □ New pet
□ Other? Describe:
General Health Information. Since Your Last Visit:
Yes No Unsure
Have you (or your child) had any major illness and/or hospitalizations?
Have you or anyone in your family (or your child’s relatives) developed new medical problems?
Are there any changes to your (or your child’s) medications?
Do you (or your child) smoke?
Do you or any adults who are around you (or your child) smoke (includes inside or outside the house)?
Do you (or your child) currently follow a low cholesterol diet?
□ No □ Yes, always □ Yes, sometimes □ Yes, seldom
Do you (or your child) check your blood pressure?
□ No □ Yes, everyday □ Yes, weekly □ Yes, every other week □ Yes, monthly
Do you (or your child) currently take medication for High Cholesterol?
□ No □ Yes □ Names of medication(s):
Ask your (or your child’s) doctor about any specific concerns about high cholesterol.
Would you like to get more information on any of the topics below?
Medications/Treatments Symptoms/Complications Health Promotion Nutrition
• High Cholesterol • Signs of High Blood Pressure • Smoking Cessation • Healthy diet
Medicine
• Normal Range Cholesterol • High Cholesterol • Calorie intake
• Lab tests to check/ Prevention
• Complications of High • Healthy snacks
monitor
Cholesterol • Exercise routine
• Decrease fat
• Weight loss
• High risk factors Cholesterol • When to call doctor intake
• Cholesterol specialist
• Causes of High Cholesterol • Dental appointment • Alcohol intake
• Herbal remedies
This is not a self-diagnosis tool or a treatment plan. Please consult your doctor and share this with your doctor at your next visit.
