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                              Your Hospital Name                                                                                                                                                             Address                                                                                                                                                      Street, City, State, and Zip Code                                                                                                                                                   Phone Number                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             ╔══════════════════════╗                                                                                                                                                  ║ CARDIAC RISK PROFILE ║                                                                                                                                                  ╚══════════════════════╝                                                                                                                                                                                                                                                                                                 ╔═════════════════════════════════════════╤════════════╤══════════╤═══════════╗                                                                                           ║Patient:                                 │ Room:      │ Sex:     │ Age:      ║                                                                                           ╟─────────────────────────────┬───────────┴────────────┴┬─────────┴───────────╢                                                                                           ║Medical Record Number:       │ Date of Birth:          │ Doctor:             ║                                                                                           ╟───────────────────────┬─────┴────────────────┬────────┴───────┬─────────────╢                                                                                           ║Date Collected:        │ Time Collected:      │ Drawn by:      │ Run by:     ║                                                                                           ╚═══════════════════════╧══════════════════════╧════════════════╧═════════════╝                                                                                                                                                                                                                                                                     ┌──────────────────┬─────────────────────────────────────────────────────────┐                                                                                            │ Test Results:    │Normal Ranges:                                           │                                                                                            ├──────────────────┼─────────────────────────────────────────────────────────┤                                                                                            │ ╔═════════════╗  │                                                         │                                                                                            │ ║Triglycerides║  │NOTE: Non-fasting specimens may be grossly elevated.     │                                                                                            │ ╟─────────────╢  │                                                         │                                                                                            │ ║        mg/dl║  │0 - 210 mg/dl                                            │                                                                                            │ ╚═════════════╝  │                                                         │                                                                                            ├──────────────────┼─────────────────────────────────────────────────────────┤                                                                                            │ ╔═════════════╗  │                                                         │                                                                                            │ ║   Total     ║  │                                                         │                                                                                            │ ║ Cholesterol ║  │<200 mg/dl - Desirable                                   │                                                                                            │ ╟─────────────╢  │200-240 mg/dl - Borderline                               │                                                                                            │ ║        mg/dl║  │>240 mg/dl - High                                        │                                                                                            │ ╚═════════════╝  │                                                         │                                                                                            ├──────────────────┼─────────────────────────────────────────────────────────┤                                                                                            │ ╔═════════════╗  │                                                         │                                                                                            │ ║    HDL      ║  │                                                         │                                                                                            │ ║ Cholesterol ║  │                                                         │                                                                                            │ ╟─────────────╢  │                                                         │                                                                                            │ ║        mg/dl║  │30 - 90 mg/dl                                            │                                                                                            │ ╠═════════════╣  │                                                         │                                                                                            │ ║ % of total  ║  │                                                         │                                                                                            │ ║ Cholesterol ║  │Low Risk for CHD     = > 23%                             │                                                                                            │ ╟─────────────╢  │Average Risk for CHD = Male: 16-23%   F: 18-23%          │                                                                                            │ ║         %   ║  │High Risk for CHD    = Male: < 16%    F: < 18%           │                                                                                            │ ╚═════════════╝  │                                                         │                                                                                            ├──────────────────┼─────────────────────────────────────────────────────────┤                                                                                            │ ╔═════════════╗  │NOTE:  Values will be falsely depressed if Triglycerides │                                                                                            │ ║     LDL     ║  │       are greater than 400 mg/dl                        │                                                                                            │ ║ Cholesterol ║  │                                                         │                                                                                            │ ╟─────────────╢  │<130 mg/dl - Desirable                                   │                                                                                            │ ║        mg/dl║  │130-159 mg/dl - Borderline                               │                                                                                            │ ╚═════════════╝  │>159 mg/dl - High Risk                                   │                                                                                            └──────────────────┴─────────────────────────────────────────────────────────┘                                                                                                                                                                                                                                                                                                                                                                                                                                                Normal Ranges from: The National Cholesterol Education Program (NCEP) Adult                                                                                                                   Treatment Panel Report (October, 1987)