Tina Bansal, MD
800 E Woodfield Rd, Ste 113. Schaumburg, IL 60173
Phone: 847-686-6866 Fax: 847-706-9891
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.
1. Have you suffered from any of the following:
Bulging of Eyes
Increased frequency of stool
Enlargement of the neck
Tenderness of the neck
Heart Racing without reason
Swelling of face, hands, feet
2. Do you experience hot flashes? YesNo
If yes, how frequent? times a week/month.
What do they feel like?
3. Do you incorporate dairy into your diet? YesNo
If yes, how many servings per day?
4. Have you had a Bone Density Scan (DEXA)? YesNo
If yes, when was this completed? (date)
Where was this completed? (name of facility)
5. Do you experience acne? YesNo
6. Do you experience excess hair on your body or face?YesNo
7. Do you experience hair loss? YesNo
8. Have you been experiencing unexplained weight gain? YesNo
If yes, for how long? months. Amount gained in this time lbs.
9. Have you been experiencing unexplained weight loss? YesNo
If yes, for how long? months. Amount lost in this time lbs.
Thank you for taking the time to complete our health history forms!