Thyroid Evaluation – aedoctors

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

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:


1. Have you suffered from any of the following:



Dry Eyes

Dry Skin


Bulging of Eyes

Hair Loss

Heat Intolerance


Weight Gain


Increased frequency of stool

Cold Intolerance

Increased Sweating

Enlargement of the neck



Tenderness of the neck

Irregular Menstruation

Heart Racing without reason

Difficulty Swallowing

Swelling of face, hands, feet

Weight Loss


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

Underactive Thyroid Date diagnosed(MM-DD-YYYY):
Overactive Thyroid Date diagnosed(MM-DD-YYYY):
Thyroid Nodules Date diagnosed:
Thyroid Cancer Date diagnosed:

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

4. Have you had any imaging of your Thyroid? (Thyroid ultrasound, CT neck, Whole body scan)
Date(MM-DD-YYYY): 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(MM-DD-YYYY): Facility: Thyroid Surgery
If yes, Date(MM-DD-YYYY): Facility:

6. Have you ever had antibody testing for your thyroid condition?

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