General Evaluation – aedoctors

Tina Bansal, MD
800 E Woodfield Rd, Ste 113. Schaumburg, IL 60173
Phone: 847-686-6866 Fax: 847-706-9891

General Evaluation

Please fill this evaluation out to the best of your ability. The provider will be going over this in detail
with you during your office visit.

Patient Name:

DOB(MM-DD-YYYY):

1. Have you suffered from any of the following:

Fatigue

Anxiety

Dry Eyes

Dry Skin

Tremors

Bulging of Eyes

Hair Loss

Heat Intolerance

Diarrhea

Weight Gain

Weakness

Increased frequency of stool

Cold Intolerance

Increased Sweating

Enlargement of the neck

Constipation

Palpitations

Tenderness of the neck

Irregular Menstruation

Heart Racing without reason

Difficulty Swallowing

Swelling of face, hands, feet

Weight Loss

Hoarseness

2. Do you experience hot flashes?
If yes, how frequent? times a week/month.

What do they feel like?

3. Do you incorporate dairy into your diet?
If yes, how many servings per day?

4. Have you had a Bone Density Scan (DEXA)?

If yes, when was this completed? (date:MM-DD-YYYY)

Where was this completed? (name of facility)

5. Do you experience acne?

6. Do you experience excess hair on your body or face?

7. Do you experience hair loss?

8. Have you been experiencing unexplained weight gain?

If yes, for how long? months. Amount gained in this time lbs.

9. Have you been experiencing unexplained weight loss?
If yes, for how long? months. Amount lost in this time lbs.

Thank you for taking the time to complete our health history forms!