Form MO650-9399 "Metabolic Syndrome Screening and Monitoring Tool" - Missouri

What Is Form MO650-9399?

This is a legal form that was released by the Missouri Department of Mental Health - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2010;
  • The latest edition provided by the Missouri Department of Mental Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form MO650-9399 by clicking the link below or browse more documents and templates provided by the Missouri Department of Mental Health.

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Download Form MO650-9399 "Metabolic Syndrome Screening and Monitoring Tool" - Missouri

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STATE OF MISSOURI
DEPARTMENT OF MENTAL HEALTH
METABOLIC SYNDROME SCREENING AND MONITORING TOOL
NAME
DOB
AGENCY
DCN # (IF AVAILABLE)
Baseline
Subsequent Values
Date
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
Height (in) _____
Weight (lbs)
BMI (kg/m2)
Waist Circumference
BMI Monitoring
BMI ↑ 25 - overweight
BMI ↑ 30 - obese
Waist Circumference Monitoring
Females ↓ 35" or Men ↓ 40" within normal limits
Females ↑ 35" or Men ↑ 40" - prediabetic risk factor
Baseline
Subsequent Values
Date
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
Blood Pressure (mmHg)
Manual/Automated
M/A
M/A
M/A
M/A
M/A
M/A
M/A
M/A
Blood Pressure Monitoring
Normal - BP 120/80 and below, Prehypertension - BP 120/80 - 139/89, Hypertension - 140/90 and above
Baseline
Subsequent Values
Date
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
Plasma Glucose (mg/dl)
Fasting - Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
and/or Hgb A1c
Fasting Plasma Glucose &/or Hgb A1c
FPG ↓ 100 mg/dl or Hgb A1c ↓ 6.0 within normal limits
FPG 100 - 125 mg/dl is indicative of prediabetes
Observe the patient for s/s of diabetes i.e.: wt gain (increase or decrease), polyuria or polydipsia.
FPG ↑ 126 mg/dl or Hgb A1c ↑ 6.1 indicates diabetic state
Baseline
Subsequent Values
Date
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
Total Cholesterol (mg/dl)
LDL (mg/dl)
HDL (mg/dl)
Triglycerides (mg/dl)
Lipid Panel Monitoring
LDL ↓ 130 mg/dl, HDL ↑ 40 mg/dl &/or Triglycerides ↓ 150 mg/dl within normal limits
LDL ↑ 130 mg/dl, HDL ↓ 40 mg/dl &/or Triglycerides ↑ 150 mg/dl at risk for hyperlipidemia
Taking antipsychotic?
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Pregnant?
Y/N/U
Y/N/U
Y/N/U
Y/N/U
Y/N/U
Y/N/U
Y/N/U
Y/N/U
Smoker?
Y/N/U
Y/N/U
Y/N/U
Y/N/U
Y/N/U
Y/N/U
Y/N/U
Y/N/U
Patient refused
Date ____/____/____
Requested order from outside provider
Date ____/____/____
Screeners Initials
MO 650-9399 (10-10)
STATE OF MISSOURI
DEPARTMENT OF MENTAL HEALTH
METABOLIC SYNDROME SCREENING AND MONITORING TOOL
NAME
DOB
AGENCY
DCN # (IF AVAILABLE)
Baseline
Subsequent Values
Date
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
Height (in) _____
Weight (lbs)
BMI (kg/m2)
Waist Circumference
BMI Monitoring
BMI ↑ 25 - overweight
BMI ↑ 30 - obese
Waist Circumference Monitoring
Females ↓ 35" or Men ↓ 40" within normal limits
Females ↑ 35" or Men ↑ 40" - prediabetic risk factor
Baseline
Subsequent Values
Date
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
Blood Pressure (mmHg)
Manual/Automated
M/A
M/A
M/A
M/A
M/A
M/A
M/A
M/A
Blood Pressure Monitoring
Normal - BP 120/80 and below, Prehypertension - BP 120/80 - 139/89, Hypertension - 140/90 and above
Baseline
Subsequent Values
Date
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
Plasma Glucose (mg/dl)
Fasting - Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
and/or Hgb A1c
Fasting Plasma Glucose &/or Hgb A1c
FPG ↓ 100 mg/dl or Hgb A1c ↓ 6.0 within normal limits
FPG 100 - 125 mg/dl is indicative of prediabetes
Observe the patient for s/s of diabetes i.e.: wt gain (increase or decrease), polyuria or polydipsia.
FPG ↑ 126 mg/dl or Hgb A1c ↑ 6.1 indicates diabetic state
Baseline
Subsequent Values
Date
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
Total Cholesterol (mg/dl)
LDL (mg/dl)
HDL (mg/dl)
Triglycerides (mg/dl)
Lipid Panel Monitoring
LDL ↓ 130 mg/dl, HDL ↑ 40 mg/dl &/or Triglycerides ↓ 150 mg/dl within normal limits
LDL ↑ 130 mg/dl, HDL ↓ 40 mg/dl &/or Triglycerides ↑ 150 mg/dl at risk for hyperlipidemia
Taking antipsychotic?
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Pregnant?
Y/N/U
Y/N/U
Y/N/U
Y/N/U
Y/N/U
Y/N/U
Y/N/U
Y/N/U
Smoker?
Y/N/U
Y/N/U
Y/N/U
Y/N/U
Y/N/U
Y/N/U
Y/N/U
Y/N/U
Patient refused
Date ____/____/____
Requested order from outside provider
Date ____/____/____
Screeners Initials
MO 650-9399 (10-10)
Pre-diabetes Screening and Monitoring Guidelines for Children and Adolescents
Age Range
Under Age 10
10-17 Years
> 90th Percentile in Weight unless
BMI is:
puberty has occurred. If either is
• 85th percentile for age & gender
Over
present follow 10-17 guidelines.
• Or 85th percentile for height
Weight
• Or Weight is > 120% of ideal for height
AND Two risk factors
Two of the following:
• Family history of type 2 diabetes (1st/2nd degree)
Other
• Race ethnicity (Native American, African American, Hispanic American,
Risk
Asian/South Pacific Islander)
Factors
• Signs of insulin resistance (acanthosis nigricans, hypertension, dyslipidemia,
polycystic ovary syndrome)
Screening Tests
Requires additional testing if:
Fasting Plasma Glucose (FPG)
100-125 mg/dL (may indicate pre-diabetes)
Screening
Fasting Plasma Glucose (FPG)
126 mg/dL (may indicate diabetes)
Impaired Glucose tolerance (IGT)
2 hrs after 75g glucose, value is > 140-199
(pre-diabetes); > 200 diabetes)
Frequency
Every two years
Notify physician and dietician of
Results Abnormal
Results Normal
need for consult.
1. Repeat tests on subsequent day to diagnose
Screen as in 1-3
2. Implement treatment plan including lifestyle modification
Action
3. Screen for Cardiovascular Disease Risk Factors:
• HDL < 40 mg/dL
• Fasting Triglycerides > 150 mg/dL
• Blood Pressure > 130/85 mm/Hg
Metabolic Syndrome cannot be
diagnosed but further
measurements should be made if
there is a family history of
Rationale
metabolic syndrome, type 2
Diabetes, dyslipidemia,
cardiovascular disease,
hypertension and/or obesity.
MO 650-9399 (10-10)
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