Screeningsformulier Blanco

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Voorbeeld van een screeningsformulier cardiovasculair risico

Geslacht, naam :
Geboortedatum, afdeling :

monitoring cardiovasculair risico bij a-typische antipsychotica.
antipsychoticum dosering startdatum stopdatum reden

Andere medicatie dosering start Stop/wijziging

Anamnese
Bestaand vaatlijden of DM

Roken

alcohol
Familie anamnese

etniciteit

beweging

Lichamelijk onderzoek
nulmeting 3 mnd 6 mnd 1 jaar 2 jaar 3 jaar 4 jaar
Datum
Bloeddruk
sys / dia
pols
lengte X=niet X X X X X
gewicht
BMI
buikomvang
Bij bloeddruk boven 90/150 wekelijks controleren en na 4 x te hoog doorsturen naar somaticus

Labcontroles
Nuchter prikken, dus vanaf 12 uur daarvoor geen eten en alleen water
nulmeting 1 mnd 2 mnd 3 mnd 6 mnd 1 jaar 2 jaar
Datum
Tot. chol X=niet X=niet
triglyceride X X
Hdl X X
Ldl X X
Ratio X X
N Glucose
HbA1c
Bij een metabool syndroom of lab buiten de referentiewaarden doorsturen naar somaticus

Metabool Syndroom 3 of meer van onderstaande
risicofactoren
Centrale obesitas, Mannen >102 cm
gemeten als buikomvang Vrouwen > 88 cm
Triglyceride >1,7 mmol/l
HDL cholesterol Mannen <1.03 mmol/l
Vrouwen <1,3 mmol/l
Bloeddruk >130/>85 mm Hg
Nuchter glucose >6,1 mmol/l
NCEP/ATP III criteria metabool syndroom ‘93

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Screeningsformulier Blanco

1. Geslacht, naam : Geboortedatum, afdeling : monitoring cardiovasculair risico bij a-typische antipsychotica. antipsychoticum dosering startdatum stopdatum reden Andere medicatie dosering start Stop/wijziging Anamnese Bestaand vaatlijden of DM Roken alcohol Familie anamnese etniciteit beweging Lichamelijk onderzoek nulmeting 3 mnd 6 mnd 1 jaar 2 jaar 3 jaar 4 jaar Datum Bloeddruk sys / dia pols lengte X=niet X X X X X gewicht BMI buikomvang Bij bloeddruk boven 90/150 wekelijks controleren en na 4 x te hoog doorsturen naar somaticus Labcontroles Nuchter prikken, dus vanaf 12 uur daarvoor geen eten en alleen water nulmeting 1 mnd 2 mnd 3 mnd 6 mnd 1 jaar 2 jaar Datum Tot. chol X=niet X=niet triglyceride X X Hdl X X Ldl X X Ratio X X N Glucose HbA1c Bij een metabool syndroom of lab buiten de referentiewaarden doorsturen naar somaticus Metabool Syndroom 3 of meer van onderstaande risicofactoren Centrale obesitas, Mannen >102 cm gemeten als buikomvang Vrouwen > 88 cm Triglyceride >1,7 mmol/l HDL cholesterol Mannen <1.03 mmol/l Vrouwen <1,3 mmol/l Bloeddruk >130/>85 mm Hg Nuchter glucose >6,1 mmol/l NCEP/ATP III criteria metabool syndroom ‘93

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Screeningsformulier Blanco

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