THYROID/PARATHYROID...THYROID/PARATHYROID Name: _____ Date: _____ 1. Have you had a thyroid...
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THYROID/PARATHYROID Name: ______________________________________________________Date:_____________________________ 1. Have you had a thyroid ultrasound for this problem? Yes________ No_________ When____________ Where completed_________________________ 2. Have you had a thyroid nuclear medicine scan for this problem? Yes________ No________ When_____________ Where completed__________________________ 3. Have you ever had a biopsy of your thyroid? Yes________ No__________ When__________________ Where completed______________________ 4. Have you had blood testing done for evaluation of the function of your thyroid gland? Yes_____ When________________ Where completed_________________________ 5. Can you feel the area of concern? Yes__________ No_______________ If not, can a health care provider feel the area of concern? Yes___________ No_____________ Please mark area of palpable lump(s) on this diagram: Right Left Has the area changed since it was first noted? Yes___________ No___________ Is it bigger smaller Is it more less noticeable? What size is it? BB Pea Grape Walnut Larger 6. Do you have a family history of thyroid problems (circle: cancer/goiter) Family member and approximate age of diagnosis___________________________________ Family history of pancreatic or pituitary tumor? ________________________________________ 7. Have you ever had thyroid cancer? Yes______ No_______ Age at diagnosis _______________ Name of oncologist___________________ Name of radiation/chemotherapy ___________________ Circle all types of treatment required: surgery/radioactive iodine/chemotherapy 8. Have you ever or are you currently taking thyroid hormone replacement therapy? Yes______ No______ Name of medication_________________________ Length of time on this medication_______________ 9. Please check mark/circle ALL symptoms you have noticed: _____swollen glands or lumps in your neck (right/left side, single or multiple lumps) _____change in speaking or singing voice (hoarseness/husky/rough/harsh/lower pitch than before) _____change/difficulty in swallowing _____Osteoporosis _____Bone Fractures _____Loss of Appetite _____Constipation _____Heartburn or abdominal pain _____Impaired thinking and memory _____Weakness and fatigue
Transcript of THYROID/PARATHYROID...THYROID/PARATHYROID Name: _____ Date: _____ 1. Have you had a thyroid...
THYROID/PARATHYROID Name: ______________________________________________________Date:_____________________________ 1. Have you had a thyroid ultrasound for this problem? Yes________ No_________ When____________ Where completed_________________________ 2. Have you had a thyroid nuclear medicine scan for this problem? Yes________ No________ When_____________ Where completed__________________________ 3. Have you ever had a biopsy of your thyroid? Yes________ No__________ When__________________ Where completed______________________ 4. Have you had blood testing done for evaluation of the function of your thyroid gland? Yes__ No________ When________________ Where completed_________________________ 5. Can you feel the area of concern? Yes__________ No_______________ If not, can a health care provider feel the area of concern? Yes___________ No_____________ Please mark area of palpable lump(s) on this diagram: Right Left
Has the area changed since it was first noted? Yes___________ No___________ Is it bigger or smaller Is it more or less noticeable? What size is it? BB Pea Grape Walnut Larger
6. Do you have a family history of thyroid problems (circle: cancer/goiter)
Family member and approximate age of diagnosis___________________________________ Family history of pancreatic or pituitary tumor? ________________________________________
7. Have you ever had thyroid cancer? Yes______ No_______ Age at diagnosis _______________
Name of oncologist___________________ Name of radiation/chemotherapy ___________________ Circle all types of treatment required: surgery/radioactive iodine/chemotherapy
8. Have you ever or are you currently taking thyroid hormone replacement therapy? Yes______ No______ Name of medication_________________________ Length of time on this medication_______________ 9. Please check mark/circle ALL symptoms you have noticed: _____swollen glands or lumps in your neck (right/left side, single or multiple lumps) _____change in speaking or singing voice (hoarseness/husky/rough/harsh/lower pitch than before) _____change/difficulty in swallowing _____Osteoporosis _____Bone Fractures _____Loss of Appetite _____Constipation _____Heartburn or abdominal pain _____Impaired thinking and memory _____Weakness and fatigue _____Kidney Stones
