Thyroid Questionnaire
Patient's name
*
First Name
Middle (Optional)
Last Name
Birth date
*
/
Month
/
Day
Year
Referring MD
*
2nd MD to get report
Reason your MD ordered this exam
*
Date of prior thyroid ultrasound
*
Where was the prior ultrasound done?
Current thyroid medications
*
Results of recent thyroid blood tests
*
Enter NA if not applicable
Previously diagnosed with
*
Underactive (hypothyroid)
Overactive (hyperthyroid)
Thyroid nodule
Goiter
Thyroid cancer
No thyroid abnormalities
Have you had any of the following?
*
Thyroid needle biopsy
Thyroid surgery
Radioactive iodine treatment
Radiation therapy to the head, neck, or chests
Family history of thyroid cancer
Family history of benign thyroid disease
No thyroid procedures or family history
Do you have a known latex allergy?
*
* YES *
No
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