New Patient Questionnaire - Thyroid
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New Patient Questionnaire - Thyroid
Name
Date _ _Primary Care Physician _ _ _ _ _ __
Have you had recent thyroid tests?
What were the results? ___________
Have you had a thyroid: scan _ _ ultrasound
or radioactive iodine therapy _ _ _ __
If yes - where and when?
Have you had thyroid surgery?
\V'hen was it? _ _ _ _ _ _ _ _ _ _ _ _ _
~
Have you taken thyroid medication?
If yes, when? _ _ _ _ __
If currently taking, name of pill _ _ _ _ _ __
Last dose
When was your last pregnancy? ________________
Please circle if you take any of the following:
birth control pills
female hormones
iron
iodine drops
kelp
calcium
Questran
Cordarone (amiodarone)
I Illness/Medical History
Self
Family
Details
I
Diabetes
i
Heart Disease
Kidney Disease
Thyroid Disease
Adrenal Disorder
Pituitary Disorder
Stroke
Cancer
i
High Cholesterol
High Blood Pressure
I Osteoporosis
I
Other
I
I
I
,
.....
Please list any previous surgeries and their dates. ___________________
Please list all medications, including over the counter and herbal medications with doses, ifknown.
Are you allergic to any medications? _________________________
I
M.D. Initials:
PLEASE MAKE SURE TO COMPLETE BOTH SIDES OF THIS INFOR\'IATION SHEET.
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Parent category: Life