Medical Assessment for Cholesterol

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Patient Information

Are you 10-75 years old?

Yes

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For females, are you currently pregnant or breastfeeding?

Yes

If you get pregnant while taking this medication, tell your doctor right away.

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Patient Symptoms

Have you been told by your doctor that you need statins?

Have you had a blood test in the past 6 months wherein your cholesterol, LDL (bad cholesterol), or triglyceride (fats) levels are high?

Yes

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Have you been experiencing these symptoms recently?

Yes

These may be signs of rhabdomyolysis, a serious syndrome due to muscle injury.

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Medical History

Have you had a normal blood test to check for your liver function (SGPT/ALT, SGOT/AST) in the past 6 months?

Yes

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Do you have or have you had any of the following?

Yes

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Are you currently taking any of these drugs?

Yes

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Consent

Do you agree to the following?

You will take the medicine as directed by your doctor or as indicated in the information leaflet supplied with the medication
You will contact us and inform your doctor if you experience any side effects of treatment, if you start new medication, or if your medical conditions change during treatment
You will regularly follow up with your doctor to monitor blood cholesterol and sugar levels and liver function
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly and that incorrect information can be hazardous to your health
You understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber

Yes

Good Dr.