Patient Information
Name: _________________________
Date: _________________________
Primary Care Provider: _________________________
Important Numbers
- Primary Care Provider: ________________
- Cardiologist: ________________
- Emergency Contact: ________________
- Local Emergency Room: ________________
My Cholesterol Numbers
- Total Cholesterol Goal: < 200 mg/dL
- LDL ("Bad") Cholesterol Goal: < 100 mg/dL
- HDL ("Good") Cholesterol Goal: > 40 mg/dL (men), > 50 mg/dL (women)
- Triglycerides Goal: < 150 mg/dL
My Latest Results (Date: _______)
- Total: _______ mg/dL
- LDL: _______ mg/dL
- HDL: _______ mg/dL
- Triglycerides: _______ mg/dL
Current Medications
- Medication: ________________ Dose: _______ Time: _______
- Medication: ________________ Dose: _______ Time: _______
- Medication: ________________ Dose: _______ Time: _______
Warning Signs to Monitor
Seek Immediate Medical Attention If:
- Severe chest pain or pressure
- Shortness of breath
- Pain in jaw, neck, or left arm
- Sudden severe headache
- Dizziness or fainting
- Sudden weakness or numbness
Emergency Action Steps
-
If experiencing chest pain:
- Stop activity immediately
- Take prescribed nitroglycerin if available
- Call 911 if pain persists
-
For other symptoms:
- Sit or lie down
- Call emergency contact
- Contact healthcare provider
Daily Management Plan
- Take medications as prescribed
- Follow low-cholesterol diet
- Exercise according to provider's recommendations
- Monitor blood pressure if instructed
- Keep all medical appointments
Notes
Keep this plan readily available and share with family members