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Biometric Screening: Fasting
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Past Medical History
• • •
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Further details regarding above:
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Allergies & Current Medication fields completed?
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"Vitals" tab completed
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BP >140/90 but <180/110. Refer for recheck/PMD
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BP >180/110: Referred for STAT eval.
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BMI is over 25, lifestyle interventions advised
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Test results
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A1C Interpretation
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HbA1C
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Total Cholesterol Intepretation
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Total Cholesterol
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LDL Intepretation
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LDL
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HDL Intepretation
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HDL
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Fasting Glucose Intepretation
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Glucose
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Triglyceride Intepretation
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Triglycerides
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If follow up recommended, where will pt go?
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Explanation of need to contact MD on-call:
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Name of examiner:
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