Get the free thyroid history form - ohsu

THYROID AND PARATHYROID PROGRAM Patient Registration Label INITIAL VISIT HEALTH HISTORY FORM Referring MD: Specialty: Address: Cite/State/Zip: Phone: Fax: Primary/Other MD: Specialty: Address: Cite/State/Zip:

How to fill out thyroid history form

How to fill out a thyroid history form:

1. Start by writing your personal information, such as your full name, date of birth, and contact details.
2. Provide a thorough medical history, including any previous diagnosis or treatment related to your thyroid or other endocrine conditions.
3. Indicate any symptoms you have experienced, such as fatigue, weight changes, or changes in mood or energy levels.
4. Specify any medication or supplements you are currently taking, including the dosage and frequency.
5. Mention any allergies or adverse reactions you have had to medications in the past.
6. Include any relevant family history of thyroid or endocrine disorders, as this might be important for genetic considerations.
7. Describe any previous surgeries or procedures related to your thyroid or endocrine system.
8. Provide a comprehensive list of all healthcare professionals you have seen in the past for thyroid-related concerns.
9. If applicable, describe any previous imaging tests or laboratory tests you have undergone regarding your thyroid.
10. Sign and date the form to acknowledge that the information you have provided is accurate.

Who needs a thyroid history form:

1. Individuals who have been diagnosed with thyroid disorders such as hypothyroidism, hyperthyroidism, thyroid nodules, or thyroid cancer.
2. Patients who are experiencing symptoms that might be related to thyroid dysfunction, such as fatigue, weight changes, or mood swings.
3. People with a family history of thyroid disorders, as genetic factors can play a role in thyroid-related conditions.
4. Individuals scheduled for thyroid-related surgeries or procedures.
5. Patients who require close monitoring of their thyroid function due to medications or treatments they are receiving.
6. People participating in research studies or clinical trials focused on thyroid disorders.
7. Individuals seeking a second opinion or consultation from a specialist regarding their thyroid health.

For pdfFiller’s FAQs

What is thyroid history form?

The thyroid history form is a document used to gather information about an individual's medical history related to thyroid conditions.

Who is required to file thyroid history form?

The thyroid history form is typically required to be filed by individuals who have a suspected or diagnosed thyroid disorder, or by those who are undergoing thyroid-related medical treatments.

How to fill out thyroid history form?

To complete the thyroid history form, individuals will need to provide detailed information about their medical history, including any previous thyroid conditions, current symptoms, medications, and treatments.

What is the purpose of thyroid history form?

The purpose of the thyroid history form is to gather comprehensive information about an individual's thyroid-related medical history, which can assist healthcare professionals in diagnosing and treating thyroid disorders.

What information must be reported on thyroid history form?

The thyroid history form typically requests information such as previous thyroid disorders, symptoms experienced, medications, surgeries, family history of thyroid conditions, and any other relevant medical information.

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