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.
Patient Name:
DOB:
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? 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!