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facebook.com/gormezdengelmeyelim gormezdengelmeyelim.com HASTA TAKİP KİTAPÇIĞI TARİH: ..................../..................../............................... Hasta adı, soyadı: ........................................................................................................................................ Aile Öyküsü Geçirilmiş psikiyatrik hastalık: ................................................................................................ ................................................................................................................................................................................................. Yaş: ................................................................................................................................................................................. Boy: .............................................. cm Kilo: ......................................... kg Geçirilmiş KV hastalık: ....................................................................................................................... Şikayeti: .................................................................................................................................................................... ................................................................................................................................................................................................ ................................................................................................................................................................................................ ................................................................................................................................................................................................ ................................................................................................................................................................................................ Özgeçmiş: ................................................................................................................................................................ ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................ Kullanmakta olduğu ilaçlar: ......................................................................................................... ................................................................................................................................................................................................ Tanı: ............................................................................................................................................................................. Verilen tedavi: ................................................................................................................................................. ................................................................................................................................................................................................ ................................................................................................................................................................................................ Hekimin adı-soyadı, kaşesi: İLK ZİYARET TARİH: ................../................../............................. BİR SONRAKİ ZİYARETE KADAR HEKİM ÖNERİLERİ Kilo (kg): ................................................................................................................................................................. ................................................................................................................................................................................................. Bel çevresi (cm): ......................................................................................................................................... ................................................................................................................................................................................................. VKİ (kg/m2): ...................................................................................................................................................... ................................................................................................................................................................................................. Açlık kan şekeri (mg/dl): ................................................................................................................ ................................................................................................................................................................................................. Kan basıncı (mmHg) sistolik/diyastolik: .................................................................... ................................................................................................................................................................................................. TG (mg/dl): ........................................................................................................................................................ ................................................................................................................................................................................................. LDL kolesterol (mg/dl): ..................................................................................................................... ................................................................................................................................................................................................. HDL kolesterol (mg/dl): ..................................................................................................................... ................................................................................................................................................................................................. Total kolesterol (mg/dl): .................................................................................................................. Serum prolaktin düzeyi (ng/ml): .......................................................................................... Sigara kullanımı: ........................................................................................................................................... Hekimin adı-soyadı, kaşesi: 3. HAFTA TARİH: ................../................../............................. BİR SONRAKİ ZİYARETE KADAR HEKİM ÖNERİLERİ Kilo (kg): ................................................................................................................................................................. ................................................................................................................................................................................................. Bel çevresi (cm): ......................................................................................................................................... ................................................................................................................................................................................................. VKİ (kg/m2): ...................................................................................................................................................... ................................................................................................................................................................................................. Açlık kan şekeri (mg/dl): ................................................................................................................ ................................................................................................................................................................................................. Kan basıncı (mmHg) sistolik/diyastolik: .................................................................... ................................................................................................................................................................................................. TG (mg/dl): ........................................................................................................................................................ ................................................................................................................................................................................................. LDL kolesterol (mg/dl): ..................................................................................................................... ................................................................................................................................................................................................. HDL kolesterol (mg/dl): ..................................................................................................................... ................................................................................................................................................................................................. Total kolesterol (mg/dl): .................................................................................................................. Serum prolaktin düzeyi (ng/ml): .......................................................................................... Sigara kullanımı: ........................................................................................................................................... Hekimin adı-soyadı, kaşesi: 6. HAFTA TARİH: ................../................../............................. BİR SONRAKİ ZİYARETE KADAR HEKİM ÖNERİLERİ Kilo (kg): ................................................................................................................................................................. ................................................................................................................................................................................................. Bel çevresi (cm): ......................................................................................................................................... ................................................................................................................................................................................................. VKİ (kg/m2): ...................................................................................................................................................... ................................................................................................................................................................................................. Açlık kan şekeri (mg/dl): ................................................................................................................ ................................................................................................................................................................................................. Kan basıncı (mmHg) sistolik/diyastolik: .................................................................... ................................................................................................................................................................................................. TG (mg/dl): ........................................................................................................................................................ ................................................................................................................................................................................................. LDL kolesterol (mg/dl): ..................................................................................................................... ................................................................................................................................................................................................. HDL kolesterol (mg/dl): ..................................................................................................................... ................................................................................................................................................................................................. Total kolesterol (mg/dl): .................................................................................................................. Serum prolaktin düzeyi (ng/ml): .......................................................................................... Sigara kullanımı: ........................................................................................................................................... Hekimin adı-soyadı, kaşesi: 3. AY TARİH: ................../................../............................. BİR SONRAKİ ZİYARETE KADAR HEKİM ÖNERİLERİ Kilo (kg): ................................................................................................................................................................. ................................................................................................................................................................................................. Bel çevresi (cm): ......................................................................................................................................... ................................................................................................................................................................................................. VKİ (kg/m2): ...................................................................................................................................................... ................................................................................................................................................................................................. Açlık kan şekeri (mg/dl): ................................................................................................................ ................................................................................................................................................................................................. Kan basıncı (mmHg) sistolik/diyastolik: .................................................................... ................................................................................................................................................................................................. TG (mg/dl): ........................................................................................................................................................ ................................................................................................................................................................................................. LDL kolesterol (mg/dl): ..................................................................................................................... ................................................................................................................................................................................................. HDL kolesterol (mg/dl): ..................................................................................................................... ................................................................................................................................................................................................. Total kolesterol (mg/dl): .................................................................................................................. Serum prolaktin düzeyi (ng/ml): .......................................................................................... Sigara kullanımı: ........................................................................................................................................... Hekimin adı-soyadı, kaşesi: 6. AY TARİH: ................../................../............................. BİR SONRAKİ ZİYARETE KADAR HEKİM ÖNERİLERİ Kilo (kg): ................................................................................................................................................................. ................................................................................................................................................................................................. Bel çevresi (cm): ......................................................................................................................................... ................................................................................................................................................................................................. VKİ (kg/m2): ...................................................................................................................................................... ................................................................................................................................................................................................. Açlık kan şekeri (mg/dl): ................................................................................................................ ................................................................................................................................................................................................. Kan basıncı (mmHg) sistolik/diyastolik: .................................................................... ................................................................................................................................................................................................. TG (mg/dl): ........................................................................................................................................................ ................................................................................................................................................................................................. LDL kolesterol (mg/dl): ..................................................................................................................... ................................................................................................................................................................................................. HDL kolesterol (mg/dl): ..................................................................................................................... ................................................................................................................................................................................................. Total kolesterol (mg/dl): .................................................................................................................. Serum prolaktin düzeyi (ng/ml): .......................................................................................... Sigara kullanımı: ........................................................................................................................................... Hekimin adı-soyadı, kaşesi: 1. YIL TARİH: ................../................../............................. BİR SONRAKİ ZİYARETE KADAR HEKİM ÖNERİLERİ Kilo (kg): ................................................................................................................................................................. ................................................................................................................................................................................................. Bel çevresi (cm): ......................................................................................................................................... ................................................................................................................................................................................................. VKİ (kg/m2): ...................................................................................................................................................... ................................................................................................................................................................................................. Açlık kan şekeri (mg/dl): ................................................................................................................ ................................................................................................................................................................................................. Kan basıncı (mmHg) sistolik/diyastolik: .................................................................... ................................................................................................................................................................................................. TG (mg/dl): ........................................................................................................................................................ ................................................................................................................................................................................................. LDL kolesterol (mg/dl): ..................................................................................................................... ................................................................................................................................................................................................. HDL kolesterol (mg/dl): ..................................................................................................................... ................................................................................................................................................................................................. Total kolesterol (mg/dl): .................................................................................................................. Serum prolaktin düzeyi (ng/ml): .......................................................................................... Sigara kullanımı: ........................................................................................................................................... Hekimin adı-soyadı, kaşesi: