Dr. Russell new patient THYROID questionnaire
Name: ______________________________________ Date of Birth: __________________________
Primary Care physician: ________________________
Have you had recent thyroid blood tests?
 Yes, when? ______________ where? ____________________
 No
What were the results? ___________________________________________________________
Have you had any of the following? If so, when did you have these and where?

Thyroid nuclear medicine uptake or scan __________________________________________

Thyroid ultrasound ____________________________________________________________

Radioactive iodine surgery ______________________________________________________

Thyroid surgery ______________________________________________________________

A history of nodules in your thyroid ______________________________________________

Radiation treatment to your head or neck (not just a CT or xray) ________________________
Have you taken thyroid medication in the past (levothyroxine, synthroid, armour thyroid,
methimazole/tapazole, propylthiouracil (PTU))? If yes, when and for what purpose?
_____________________________________________________________________________
Are you currently taking thyroid medication?
 Yes, Name of pill ____________ Dose __________ Last taken ______________
 No
What time of day do you take your thyroid medication? ______________________________________
Do you eat, drink or take other medications/vitamins at the same time?
 Yes, ______________________________________________________________
 No
Are you/could you be pregnant?
 Yes
 No
When was your last pregnancy? _________________
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Please circle if you take any of the following:
Calcium pills
Iron tablets
Cordarone (amiodarone)
Iodine drops/pills
Questran/cholestyramine
Kelp
Female hormones
Birth control pills
Illness/Medical History
Diabetes
Heart Disease
Thyroid Disease
Thyroid Cancer
Adrenal Disorder
Pituitary Disease
Osteoporosis
Calcium problem
Kidney disease
Stroke
Cancer (and what type)
High blood pressure
High cholesterol
Other
Yourself
Family Members
Details
Please list any former surgeries and dates if known:
Surgeries:
Date:
Please list all medications, INCLUDING over the counter and herbal medications, with doses if known:
Medication
Dose
Frequency
Are you allergic to any medications? If so, what reaction did you have? _________________________
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Social History:

Current smoker, if checked, how much and for how many years? _________________________

Smoked in the past, If checked, how much and for how many years? ______________________

Drink alcohol, If checked, how much and how often? ___________________________________
Review of systems:
Please circle any CURRENT symptoms you are having on a FREQUENT basis
General
Head
Fatigue, generalized weakness, weight loss, weight gain, abnormally thirsty
Visual difficulty, double vision, blurred vision, change of voice, difficulty
swallowing, painful swallowing
Neck pain, neck swelling
Fast heart rate, palpitations, chest pain, shortness of breath with exertion
Shortness of breath, cough, difficulty breathing when lying down, difficulty with
breathing when raising both arms above your head
Abdominal pain, nausea, vomiting, diarrhea, constipation
Frequent daytime urination, frequent nighttime urination, frequent urinary or
vaginal infections
For women: Last menstrual period _________, irregular periods, pregnant, post
menopausal (including surgical menopause)
For men: low libido, difficulty with erections, decreased shaving frequency
Dry skin, moist skin, rash, easy/excessive bruising, thin skin, excessive acne
For women only: male pattern hair growth
Prolonged bleeding, other blood disorders
Heat intolerance, cold intolerance
Poor muscle strength, previous fracture, osteoporosis, previous foot ulcer, calf
cramping
Burning/numbness/tingling of feet, tremors, jitteriness
Depression, anxiety
Neck
Heart
Lungs
Gastrointestinal
Urinary
Reproductive
Skin
Blood
Endocrine
Musculoskeletal
Neurological
Psychological
-------------------------------------------------------FOR STAFF USE ONLY------------------------------------------------------Physical Examination:
Pulse
Resting Rate
Blood Pressure
Height
Weight
BMI
Eyes: pupils equal round and reactive to light, injection, proptosis, lid lag, stare, icterus
HEENT: moist mucus membranes, no oral lesions,
Lymphadenopathy: Palpable abnormal lymph nodes: ant/post cervical, supra/infra clavicular
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Neck: Thyromegaly _________, trachea deviated
Heart: irregular rate _______, irregular rhythm,
Chest: lungs clear to auscultation, negative Pemberton’s sign
Abdomen: soft, nontender, good bowel sounds,
Musculoskeletal: grossly intact muscle strength, no tenderness to palpation along spine/hips, intact
distance between pelvic brim and lower ribs
Extremities: no edema, palpable peripheral pulses, onychomycosis toenails
Neurological: 2 + DTRs, intact monofilament/vibratory sensation, alert, oriented
Skin: no ulcers on feet, dry skin, rash, jaundice
Psych: normal mood/affect, normal judgment
Other: ____________________________________________________________________________
Assessment/Plan:

Pt advised of how to properly take levothyroxine

Pt advised of the pros/cons of radioactive iodine, anti-thyroid drugs or surgery. He/she chooses
_______________
Pt advised of the risks of anti-thyroid drugs and is advised to stop them and contact me
immediately should he/she develop signs/symptoms of rash, jaundice/icterus, sore throat OR
fever.
Will check CBC and AST/ALT prior to starting anti-thyroid drugs



Pt advised to avoid pregnancy until thyroid levels normalize or until 2 yrs after receiving
radioactive iodine
Return to Clinic ___________________ Physician Signature: ___________________________________
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