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New Patient

Create New Account
User Email*
Demographics:
Name*
First
Age
Sex*
Are You Currently Pregnant
- Yes
- No
History of Thyroid Cancer
- Yes
- No

History Of Thyroid Conditions
HYPOTHYROIDISM:
- Autoimmune [Hashimoto’s Disease]
- Postsurgical
- Post Radiation
Date Of Diagnosis

Important Past Medical History besides hypothyroidism:
- CHF
- AFib
- CAD
- Arrhythmia
- Osteoporosis
Are you currently taking any thyroid medication?*
- Yes
- No

Name of thyroid medication:
*
- Levothyroxine
- Synthroid
- Tirosint
- Levoxyl
- Unithroid
- WP Thyroid
- NP Thyroid
- Armour Thyroid
- Liothyronine
- Cytomel
- Other
Dose*
First
Frequency*
- Daily
- Please Specify
How long have they been on this dose:
- < 2 months
- > 2 months
- > 4 months
- > 6 months
- Please Specify

Are you currently taking any of the following medication?
*
- Birth Control Pills
- Corticosteroids (Steroids)
- Amiodarone
- Lithium
- Biotin
Duration
- > 2 months
- < 2 months
- Please Specify

Do you have any known gastrointestinal issues(History of gastric bypass or celiac disease):*
- Yes
- No
Do you have any history of recent contrast exposure:(CT scan with contrast or Angiogram):*
- Yes
- No
Date Of Exposure
- < 1 month
- > 1 month
- Please Specify
Do you have any of the following symptoms:
Recent Weight Gain Or Weight Loss
- Gain
- Loss
Weight In Unit:
- Kg
- Lbs
*
Over The Course Of How Long

Are you experiencing any of the following Symptoms
- Dry Skin
- Hair Thinning
- Unable To Tolerate Cold
- Diarrhea
- Constipation
Palpitations:*
- Yes
- No
Tremors:*
- Yes
- No
Change in bowel movements recently:*
- Yes
- No
How many bowels movements per day?*
Change in menstrual period:*
- Yes
- No

Upload labs

(upload pictures and patient types in the numbers for confirmation)
Date of labs*
Please include TSH, T3, T4 if available
Drop files here or
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Thyroid Subscription
Price: $10.00
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