Thyroid and Parathyroid Diseases

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Date diagnosis established.
2. Fatigability.
3. Mental assessment.
4. Neurologic, cardiovascular, or gastrointestinal symptoms.
5. Treatments (surgery, medications, hormones), including dose, frequency, response, side effects. For C-cell hyperplasia, provide date of completion of any treatment for malignancy.
6. Symptoms due to pressure (on larynx, esophagus, etc.).
7. Cold or heat intolerance.
8. Constipation.
9. Weight gain or loss.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Thyroid size.
2. Pulse and blood pressure.
3. Eye and vision abnormalities.
4. Muscle strength.
5. Tremor.
6. Myxedema.
7. All other residuals of thyroid disease or its treatment.

D. Diagnostic and Clinical Tests:

Provide:

1. T4, T3, TSH, and/or other thyroid function tests, if needed.
2. If thyroidectomy scar is disfiguring, order color photograph.
3. Thyroid scan, if indicated.
4. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Comment on:

1. Is the disease active or in remission?

Signature:

Date: