Chart Audit For Prevalence Of Drug And Disease Indicators Page 4

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ADDITIONAL INFORMATION
D
iagnoses
Does patient have any of the following conditions? (based on written words in chart):
Diabetes
[ ] Yes [
] No
[ ] Don’t know
hypertension/high blood pressure
[ ] Yes [
] No
[ ] Don’t know
hyperlipidemia/ hypercholesteremia/ high cholesterol
[ ] Yes [
] No
[ ] Don’t know
If “NO” checked for all 3 conditions do not complete the drug lists below
Is the patient using any of the following diuretics: (√ check only if using drug)
[ ] chlorthalidone (hygroton, novo-thalidone, apo-chlorthalidone)
[ ] furosemide (lasix, novo-semide, apo-furosemide, furoside, uritol)
[ ] hydrochlorothiazide (hydrodiuril, novo-hydrazide, apo-hydro 25 (or 50) hydrochlorothiazide)
[ ] hydrochlorothiazide & spironolactone (aldactazide-25 (or 50), novo-spirozine-25 (or 50)
[ ] hydrochlorothiazide & triamterene (apo-triazide, novo-triamzide, nu-triazide, dyazide,
hydrochlorothiazide & triamterene)
[ ] indapamide (lozide, gen-indapamide, apo- indapamide)
[ ] metolazone (zaroxolyn)
[ ] spironolactone (aldactone, novo-spiroton)
[ ] triameterene (dyrenium)
[ ] hydrochlorothiazide & losartan (hyzaar)
Using any of the following ACE inhibitors: (√ check only if using drug)
[ ] benazepril (lotensin)
[ ] captopril (capoten, syn-captopril, apo-capto, nu-capto, novo-captopril, gen-captopril)
[ ] cilazapril (inhibace)
[ ]enalapril (vasotec)
[ ] fosinopril sodium (monopril)
[ ] lisinopril (prinivil, zestril)
[ ] lisinopril & hydrochlorothiazide (zestoretic, prinzide)
[ ] perindopril erbumine (coversyl)
[ ] quinapril (accupril)
[ ] ramipril (altace)
Using any of the following ARBs (√ check only if using drug)
[ ] irbesartan (avapro)
[ ] candasartan (atacard)
[ ] losartan (cozaar, hyzaar)
[ ] telmisartan (micardis)
[ ] valsartan (diovan)
Using any of the following antilipemic drugs: (√ check only if using drug)
[ ] atorvastatin (lipitor)
[ ] bezafibrate (bezalip)
[ ] cholestyramine Resin (questran, novo-cholamine light, PMS-cholestyramine,
syn-cholestyramine)
[ ] clofibrate (atromid-S, novo-fibrate)
[ ] colestipol HCL (colestid)
[ ] fenofibrate (lipidil, apo-fenofibrate, nu-fenofibrate, lipidil micro)
[ ] fluvastatin sodium (lescol)
[ ] gemfibrozil (mevacor)
[ ] pravastatin sodium (pravachol)
[ ] rosuvastatin (crestor)
[ ] simvistatin (zocor)
IMPACT Project 2006
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