Thyroid 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:

1. Have you suffered from any of the following:

2. Have you been diagnosed with thyroid problems? YesNo
If yes, which of the following were you diagnosed with?

Underactive Thyroid Date diagnosed:
Overactive Thyroid Date diagnosed:
Thyroid Nodules Date diagnosed:
Thyroid Cancer Date diagnosed:

3. Have any of your family members been diagnosed with any of these? YesNo
If yes, who?

4. Have you had any imaging of your Thyroid? (Thyroid ultrasound, CT neck, Whole body scan) YesNo
Date: Name of study:

5. Have had any procedures?Please insert date of service
Thyroid Biopsy
If yes, Date: Facility:
Radioactive Iodine Treatment
If yes, Date: Facility: Thyroid Surgery
If yes, Date: Facility:

6. Have you ever had antibody testing for your thyroid condition? YesNodon’t know

7. On your most recent blood test were you taking medication? YesNo
If yes, for how long?
Name of medication: Dose: