Rockville Internal Medicine Group
ENDOCRINOLOGY QUESTIONNAIRE
Printed Patient Name:_________________________________________ Date of Birth: __________________
REASON FOR VISIT: ___________________________________________ Today’s Date: __________________
Referring Physician: _______________________________
*Please bring all relevant X-rays, CAT scans (disc or film) as well as other diagnostic reports to your first visit.
MEDICAL HISTORY: (Mark All that Apply)
Thyroid
Hypothyroidism (underactive Thyroid)
Hyperthyroidism (overactive Thyroid)
Thyroid Nodule – Date Diagnosed:
Thyroid Cancer – Date Diagnosed:
Heart
High Blood Pressure
High Cholesterol
Heart Attack
Heart Failure
Angioplasty / Stent
Atrial Fibrillation / Flutter
Stroke
Lung
Asthma
COPD / Emphysema
Sleep Apnea
Other:
Bone
Osteopenia
Osteoporosis
Hip Fracture
Spine Fracture
Wrist Fracture
GI
Hepatitis
Celiac Disease
GERD/Reflux
Gallstones
Other:
Kidney Disease
Abnormal Kidney Function
Dialysis
Kidney Transplant
Kidney Stones
Diabetes
Age at Diagnosis:
Symptoms at Diagnosis:
Date started Medication:
Date started Insulin:
Retinopathy
Date of Last Eye Exam
Laser Therapy
Neuropathy
Increased Urinary Protein
Cancer
No
Yes
Type:
Neuro / Psychiatric
Seizures
Neuropathy
Stroke
Migraine
Eating Disorder
Alcoholism
Addiction
Depression
Anxiety
Other:
GYN
Date of First Period
How Many Pregnancies
Last Period
Hormone Replacement
Other Medical Conditions
1.
2.
3.
4.
5.
6.
Regular Irregular
Patient Name: ____________________________________ Date of Birth:____________________
SURGICAL HISTORY: (Mark All that Apply and Indicate Date Performed)
Heart Bypass
Gallbladder
Angioplasty/Stent
Thyroid Surgery
Leg Bypass
Pituitary Surgery
Hip Replacement
Other Surgeries:
Hysterectomy
1.
Ovaries Removed: yes
no
2.
3.
CURRENT MEDICATIONS :
NAME
MEDICATION ALLERGIES:
Drug Name
DOSE
FREQUENCY
_____ No Known Allergies
INDICATION
If yes, complete below:
Reaction
SOCIAL HISTORY:
Marital Status: __________________________
Children: ___ Girls _____ Boys
Occupation: ____________________________
Smoking: Current Maximum packs/day______
Former
Number of years smoked _______ Year quit _______
Never
Alcohol: _____ Drinks per week
Caffeine: _____ per day
Exercise type and frequency: ________________________________________________
Special Diet / Type / Restrictions: _____________________________________________
Patient Name: __________________________________ Date of Birth: ________________
FAMILY HISTORY: (Mark All that Apply and List Family Member)
Family Member
Diabetes:
Thyroid Nodule
Adult Onset/Type II
Goiter
Juvenile Onset/Type I
Thyroid Cancer
High Blood Pressure
Calcium Disorder
High Cholesterol
Parathyroid Disease
Heart Attack
Osteoporosis
Stroke
Hip Fracture
Hypothyroid/Underactive
Kidney Stones
Hyperthyroid/Overactive
Adrenal Disease
Cancer
Pituitary Disease
Other:
Other:
REVIEW OF SYMPTOMS: (Mark All that Apply)
General
Cardiovascular
Weight Gain
Chest Pain
lbs. in
months/yrs.
Heart Attack
Weight Loss
Heart Murmur
lbs. in
months/years
Palpitations
Sleeping Problems
Irregular Heart Beat
Fatigue
Shortness of Breath w/Walking
Fevers/Chills/Sweats
Dizziness
Skin
Swelling of Feet/Ankles
Skin Rash
Gastrointestinal
Itching
Nausea / Vomiting
New Skin Marks/Spots
Vomiting Blood
Head/Eyes/Ears/Nose/Throat
Difficulty Swallowing
Visual Problems / Changes
Heartburn/Indigestion
Type:
Abdominal Pain
Constipation / Diarrhea
Voice Changes
Reflux / Bloating
Sinus Infections
Neurological / Psychiatric
Hoarseness
Headache / Light-headedness
Sore Throats
Numbness / Tingling
Headaches
Dizziness / Vertigo / Fainting
Respiratory
Balance Problems / Falling
Coughing
Changes in Mood
Wheezing
Concentration/Memory changes
Shortness of Breath
Anxiety / Depression
Bone / Muscle
Endocrine
Joint Pain
Excessive Thirst
Muscle Pain
Excessive Urination
Bone Pain
Intolerance to heat/cold
Back Pain
Changes to Skin/Hair/Nail
Other:
Describe:
Family Member
Genitourinary
Pain with Urination
Frequent Urination
Blood in Urine
Urinating Overnight
Number of times per night
Hesitation with Urination
Incomplete Voiding
Lack of Bladder Control
Men:
Erectile Dysfunction
Changes in libido
Fertility problems
Pain or changes in Penis/Testicles
Testicular Mass / Breast Lump
Women:
Pre-menopausal
Per-menopausal
Post-menopausal
Irregular Periods
Fertility Problems
Prior Pregnancy
Prior Miscarriage/Abortion
Nipple Discharge
Hot Flashes
Endocrine (Continued)
Feeling of lump in neck
Tremor
Low Blood Sugar Reaction
Frequency:
Other:
Patient Signature: ____________________________________ Date: ______________