Medical Assessment for Cholesterol


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Patient Information

Are you 10-75 years old?

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For females, are you currently pregnant or breastfeeding?

If you get pregnant while taking this medication, tell your doctor right away.

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Patient Symptoms

Have you been told by your doctor that you need statins?


Have you had a blood test in the past 6 months wherein your cholesterol, LDL (bad cholesterol), or triglyceride (fats) levels are high?

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Have you been experiencing these symptoms recently?

  • Severe muscle pains/cramps
  • Progressive weakness
  • Bloody urine

These may be signs of rhabdomyolysis, a serious syndrome due to muscle injury.

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Medical History

Have you had a normal blood test to check for your liver function (SGPT/ALT, SGOT/AST) in the past 6 months?

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Do you have or have you had any of the following?

  • Thyroid disease
  • Liver disease
  • Kidney disease
  • Stroke that is caused by a bleed in the brain (hemorrhagic stroke)

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Are you currently taking any of these drugs?

  • Fibrates (For high triglyceride/fats levels in the blood)
  • Glecaprevir/Pibrentasvir/Telaprevir (For hepatitis C)
  • Fusidic acid (For bacterial infection)
  • Ciclosporin (For suppressing the immune system)
  • Tipranavir/ritonavir (For HIV/AIDS)

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Do you agree to the following?

  • You will take the medicine as directed by your doctor or as indicated in the information leaflet supplied with the medication
  • You will contact us and inform your doctor if you experience any side effects of treatment, if you start new medication, or if your medical conditions change during treatment
  • You will regularly follow up with your doctor to monitor blood cholesterol and sugar levels and liver function
  • The treatment is solely for your own use
  • You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly and that incorrect information can be hazardous to your health
  • You understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber

Good Dr.

If you need help with this medical assessment, you can visit our doctor's blog and have a free consultation.