Cholesterol Medication Assessment Form
Please complete this form to help us evaluate your current cholesterol medication regimen, adherence, and any issues you may be experiencing.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Have you ever been diagnosed with high cholesterol?
*
Yes
No
Which cholesterol medications are you currently taking? (Select all that apply)
*
Atorvastatin (Lipitor)
Simvastatin (Zocor)
Rosuvastatin (Crestor)
Pravastatin (Pravachol)
Ezetimibe (Zetia)
Other
How often do you take your cholesterol medication as prescribed?
*
Always
Most of the time
Sometimes
Rarely
Never
Have you experienced any side effects from your cholesterol medication?
*
No side effects
Muscle pain or weakness
Digestive problems
Liver issues
Other
Please rate your understanding of why you need to take cholesterol medication.
*
Not at all
1
2
3
4
Completely
5
1 is Not at all, 5 is Completely
Lifestyle Factors Assessment
*
Rows
Never
Rarely
Sometimes
Often
Always
Eat a heart-healthy diet
1
2
3
4
5
Exercise regularly
6
7
8
9
10
Smoke tobacco products
11
12
13
14
15
Consume alcohol
16
17
18
19
20
What challenges, if any, make it difficult for you to take your cholesterol medication as prescribed?
Do you have any questions or concerns about your cholesterol medication?
Submit Assessment
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