Metabolic Monitoring Form - Beacon Health Options

 

Metabolic Monitoring Form

Name___________________________________

Date of Birth______________________________

Baseline

4 Weeks

8 Weeks 12 Weeks Quarterly

Annually

Every 5

Years

Date

Drug and dose

prescribed

Height

Weight

Waist

circumference (at

umbilicus)

BMI (see chart )

Blood Pressure

Fasting Plasma

Glucose

Lipid Profile

HDL Cholesterol

Triglycerides

Intervention

required

The Centers for Disease Control and Prevention provides a Body Mass Index (BMI) Calculator. The BMI calculator is used to screen for

weight categories that may lead to health problems. To view and use the BMI calculator, visit the link:

 This is a guideline for monitoring of metabolic syndrome and is not intended to provide specific medical advice for individual patients. We encourage providers to review this information and apply as clinically appropriate to

each individual patient.

Reviewed: 4/13, 4/14, 4/15, 4/16, 4/17