Welcome to The Polyclinic Lipid Clinic!

Transcription

1 Dear Welcome to The Polyclinic Lipid Clinic! Your provider has referred you to the Lipid Clinic for management of your cholesterol and risk for cardiovascular events such as heart attack and stroke. Our goal is to help you lower your risk through nutrition and exercise strategies, and use of medications when necessary. We will help to manage your medication safely and maximize the benefits of treatment for you. A nurse practitioner or pharmacist, supervised by the physician medical director and cardiologist, Dr. Kier Huehnergarth, will meet with you each visit to assess your cardiovascular risk and help you set and achieve individual goals. Your primary/referring physician will be kept informed of your therapy and will continue to manage your health care needs. Laboratory tests At your appointments in the Lipid Clinic, the medical assistant will perform tests known as lipid profile and blood glucose. The lipid profile includes levels of total cholesterol, HDL cholesterol (good cholesterol) and triglycerides (fats) and calculates LDL cholesterol (bad cholesterol). The blood glucose is a measure of blood sugar. Sometimes a liver function test will be performed as needed to assess safety of certain medications. Most tests will be done by obtaining a small drop of blood from a finger stick. Additional tests may be needed through a blood sample drawn from a vein in your arm. Your Appointments Laboratory tests will be done at regular intervals to measure the achievement of individual goals. Most of these will be performed with clinic visits for immediate review with the clinician. Therefore, the nurse practitioner or pharmacist will make any adjustments in your medications and recommendations for changes in nutrition and exercise while you are in the clinic. You will receive a new plan and an appointment for your next clinic visit. The frequency of your appointments will depend on your individual risk and treatment plan. Like other medications, cholesterol medications maybe potentially harmful if not carefully monitored. When starting these medications, it is important to obtain frequent blood tests in order to maximize effectiveness and safety. As the individual goals are achieved, and safety is established, testing may be done less often. The Polyclinic Madison Center th Ave. Seattle, WA Main

2 On your first visit to the Lipid Clinic, the clinician will spend time talking with you about cardiovascular disease, diet, exercise, general health and medical history. Please complete the attached forms and return prior to your first visit. These will help us make the most of your first visit. Included is a dietary assessment form and general questionnaires (3). When completing the dietary form consider your dietary intake over a typical week and approximate how often you consume items from each food group. When filling out the questionnaires please pay particular attention to the family history section. We ask that you gather this information (age at heart attack/ stroke) to accurately assess your risk for cardiovascular events. Please list all of your medications (including over-the-counter medicines, vitamins and health remedies). Your spouse, other family member or support person is encouraged to come with you. Please complete the attached forms and return by mail or fax (206) prior to your first visit. Billing Because the Lipid Clinic is made of a team of providers, a cardiologist s name or the nurse practitioner s name may appear on your Medicare and other insurance explanation of benefit forms. Your primary care doctor, or the provider who referred you to the Lipid Clinic, will be documented in your patient record. Copays Some insurance companies require a copay at the time of visit. These copays can be made at the front desk prior to your visit with the nurse practitioner or pharmacist on the 7th floor. Location The Polyclinic Madison Center 904 7th Avenue Seattle, WA Hours The Lipid Clinic sees patients on Monday, Tuesday, Wednesday and Friday. If you need to speak to someone urgently on a weekend or after hours, call the main Polyclinic operator at (206) , identify yourself as a Lipid Clinic patient and ask to speak with the cardiologist on call. Questions? If you have questions or need information about the Lipid Clinic or your care there, please call (206) We are looking forward to helping you decrease your cardiovascular risk. Sincerely, Jessica Durham, ARNP, CLS Melissa Hull, PharmD, CLS The Polyclinic Madison Center th Ave. Seattle, WA Main

3 Lipid Clinic Name DOB / / Date Primary Care MD Cardiologist Endocrinologist Allergies to medications (please include reaction) Marital Status (Please circle) Educational Level (Please circle highest level) Single Married Widowed Partner Divorced Grade High Vocational College Occupation Do you enjoy using the internet? YES NO Do you have any physical limitations? YES NO Typical Day Activity at work Check most appropriate- deferred if retired Minimal Desk most of the day Moderate - Walking most of the day List Top 4 Commonly Eaten Foods: Intense Jogging/ cycling most of the day Typical Week Physical Activity Habits Please include length of time & how often Typical Day Dietary Intake Walking/running Please list the types of foods Gardening Breakfast Cycling Lunch Swimming Dinner Other Snacks Smoking History Never Smoked Occasional /year Smoked x yrs, Quit years ago Quit x, Restarted currently smoking /day Currently smoke day for years If smoked (please circle): cigarettes pipe cigar What are you most concerned about? Family History Please obtain as much information as possible focusing on High Cholesterol, Diabetes, and Heart Problems with their ages of occurrence Mother Father Sibling Sibling Sibling Alcohol Intake Please quantify drinks per: Never Occasional / year Weekly / week Monthly /month Having a Heart Attack Having a Stroke Liver Problems Other Have you had problems with cholesterol lowering medications in the past? No If so please list medication and reaction

4 Current Medications & Dosages Do you take supplements? No If so please list Please list any areas you would like to focus on or any concerns that you have pertaining to your cardiovascular risk. When was your last dental exam/ cleaning? Do you use an electric rechargeable toothbrush? (Please circle for next 4 questions) YES NO How often do you brush your teeth? <1x day 1/ day 2/ day 3/ day How often do you floss your teeth? Never Monthly or as needed (food stuck) Couple times a week Daily Do your gums bleed with either of the above? YES NO Past Medical History Please check all that apply & your age when diagnosed/ occurred: Pancreatitis Polycystic Ovarian Syndrome High Cholesterol Schizophrenia High Blood Pressure Gout Heart Attack Osteoporosis Heart Problems Obst ructive Sleep Apnea Stroke Snoring, headache and daytime tiredness Diabetes Numbness, Tingling, Burning in Hand and/or Aortic Aneurysm Feet Kidney Problems Fatty Liver Liver Problems Gestational Diabetes Poor blood flow to extremities Pre -eclampsia Thyroid Problems H. Pylori Infection Rheumatoid Arthritis Erectile dysfunction Lupus Periodontal Disease / Psoriasis Breast Cancer survivor Migraines with Aura How would you rate your current health? How many hours a night do you sleep? Excellent Fair Good Poor Do you feel well rested? YES NO Depends How would rate your current diet? How many hours of TV do you watch daily? Excellent Fair Good Poor < >6

5 Are you satisfied with your weight? Do you have/own: Yes No gym membership pedometer How would you describe your stress level: treadmill At work: minimal moderate high stationary bike At home: minimal moderate high outside bike Does it feel manageable? Yes No How do you like to relax? NWLRC Fat Intake Scale Pick the answer which best describes the way you have been eating over the past month. 1. How many ounces of meat, fish or poultry do you usually eat?** 1. I do not eat meat, fish or poultry. **3 ounces or meat, fish or chicken is 2. I eat 3 ounces or less per day. any ONE of the following: 1 reg. 3. I eat 4-6 ounces per day. hamburger, 1 chicken breast, 1 chicken 4. I eat 7 or more ounces per day. leg (thigh and drumstick), 1 pork chop or 3 slices of pre-sliced lunch meat. 2. How much cheese do you eat per week? 1. I do not eat cheese. 2. I eat whole mild cheese less than once a week and/or use only low fat cheese such as diet cheese, low fat cottage cheese, or ricotta. 3. I eat whole milk cheese once or twice per week (Cheddar, Swiss, Monterey Jack) 4. I eat whole milk cheese three or more times per week. 3. What type of milk do you use? 1. I use only skim or 1% milk, or don t use milk. 2. I usually use skim milk or 1% milk, but use others occasionally. 3. I usually use 2% or whole milk. 4. How many visible egg yolks do you use per week? 1. I avoid all egg yolks or use less than one per week and/or use only egg substitute. 2. I eat 1-2 egg yolks per week. 3. I eat 3 or more egg yolks per week. 5. How often do you eat these meats: regular hamburger, bologna, salami, hot dogs, corned beef, spareribs, sausage, bacon, braunsweiger, or liver? Do not count others. 1. I do not eat any of these meats. 2. I eat them about once per week or less. 3. I eat them about 2 to 4 times per week. 4. I eat more than 4 servings per week.

6 6. How many commercial baked goods and how much regular ice cream do you usually eat? (Examples: cake, cookies, coffee cake, sweet rolls, donuts, etc. Do not count low fat versions.) 1. I do not eat commercial baked goods and ice cream. 2. I eat commercial baked goods or ice cream once per week or less. 3. I eat commercial baked goods or ice cream 2 to 4 times per week. 4. I eat commercial baked goods or ice cream more than 4 times per week. 7. What is the main type of fat you cook with? 1. I use nonstick spray or I do not use fat in cooking. 2. I use a liquid oil (Examples: safflower, sunflower, corn, soybean, and olive oil.) 3. I use margarine 4. I use butter, shortening, bacon drippings, or lard. 8. How often do you eat snack foods such as chips, fries or party crackers? 1. I do not eat these snack foods. 2. I eat one serving of these snacks per week. 3. I eat these snacks 2 to 4 times per week. 4. I eat these snack foods more than 4 times per week. 9. What spread do you usually use on bread, vegetables, etc? 1. I do not use any spread. 2. I use diet or light margarine. 3. I use margarine. 4. I use butter. 10. How often do you eat as a snack candy bars, chocolate, or nuts? 1. Less than once per week. 2. One to 3 times per week. 3. more than 3 times per week. 11. When you use recipes or convenience foods, how often are they low fat? 1. Almost always. 2. Usually. 3. Sometimes. 4. Seldom or never. 12. When you eat away from home, how often do you choose low fat foods? 1. Almost always. 2. Usually. 3. Sometimes. 4. Seldom or never.

7 To Score: Add the points for each answer. If you have 24 or less, your diet is moderate to low in fat and cholesterol. If your score is greater than 24, look for high fat choices you could change. You have permission to copy, use, and modify this questionnaire. Please credit the Northwest Lipid Research Clinic, University of Washington, Seattle. For information about validity and scoring see Retzlaff, et al, American Journal of Public Health, February Northwest Lipid Research Clinic University of Washington 325 Ninth Avenue, Box Seattle, WA Tele 206/ ; Fatigue scale The Fatigue scale is a method of evaluating the impact of fatigue on you. This is a short questionnaire that requests you to grade your level of fatigue over the past week. During the past week, I have found that: Disagree Agree 1) My motivation is lower when I am fatigued ) Exercise brings on my fatigue ) I am easily fatigued ) Fatigue interferes with my physical functioning ) Fatigue causes frequent problems for me ) My fatigue prevents sustained physical functioning ) Fatigue interferes with carrying out certain duties and responsibilities ) Fatigue is among my 3 most disabling symptom ) Fatigue interferes with my work, family, or social life Total Score : Scoring your results: Now that you have completed the questionnaire, it is time to score your results and evaluate your level of fatigue. It s simple: Add the numbers you circled to get your total score Key: Score of >36, you may need further evaluation Score of <36 suggests that you may not be suffering from fatigue

8 Patient Health Questionnaire (PHQ-9) This questionnaire is an important part of providing you with the best healthcare possible. Name: Today s Date: MR # (to be filled in by staff): Over the last 2 weeks, how often have you been bothered by any of the following problems? 1. Little interest or pleasure in doing things. Not at all Several days More than half the days Nearly every day Feeling down, depressed or hopeless If you answered a 2 or 3 to either of the above questions, please answer the remaining 7 questions. 3. Trouble falling or staying asleep, or sleeping too much Feeling tired or having little energy Poor appetite or overeating Feeling bad about yourself or that you are a failure or have let yourself or your family down Trouble concentrating on things, such as reading the newspaper or watching television Moving or speaking so slowly that other people could have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual Thoughts that you would be better off dead or of hurting yourself in some way Staff: Please subtotal each column. Then add columns 1, 2, & 3 for Total Score =