Metabolic Syndrome Tracking Form

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N.J. DIVISION OF MENTAL HEALTH AND ADDICTION SERVICES
METABOLIC SYNDROME TRACKING
FORM
Race:
White, not of Hispanic Origin
Black, not of Hispanic Origin
Hispanic
Asian/Pacific Islander
American Indian/Alaskan Native
Other
WAIST CIRCUMFERENCE at umbilicus – baseline and every 6 months
Signatures
Baseline
Date/Time
Date/Time
Date/Time
Date/Time
Date/Time
Risk Criteria
Date/Time
>40 inch M
>35 inch F
Initials
WEIGHT– baseline and monthly
Baseline
Date/Time
Date/Time
Date/Time
Date/Time
Date/Time
Date/Time
Initials
BMI – baseline and monthly
(Height (inches):
)
Baseline
Date/Time
Date/Time
Date/Time
Date/Time
Date/Time
Risk Criteria
Date/Time
Overweight
25 – 29.9
Obese > 30
Initials
BLOOD PRESSURE – baseline and monthly
Antihypertensive Medication
Baseline
Date/Time
Date/Time
Date/Time
Date/Time
Date/Time
Risk Criteria
Date/Time
≥ 140 ≥ 90
mmHg
Initials
FASTING GLUCOSE / HEMOGLOBIN Alc
– Baseline, 12 weeks and per guidelines and annually
Anti-diabetes Medication
Baseline
Date/Time
Date/Time
Date/Time
Date/Time
Date/Time
Risk Criteria
Date/Time
Glucose ≥ 100
mg/dl or
HGBA1C > 6.0%
Initials
LIPIDS – baseline, 12 weeks and annually
Lipid-lowering Medication
Baseline
Date/Time
Date/Time
Date/Time
Date/Time
Date/Time
Risk Criteria
Date/Time
Total
≥ 200
Chol.
< 40 M
HDL
< 50 F
TG
≥ 150
LDL
≥ 100
Initials
NOTE: A patient is considered to have Metabolic Syndrome if he/she has 3 or more of the Risk Criteria.
METABOLIC SYNDROME TRACKING FORM
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