Email address

Today's Date

Name

Age

Birthday

Gender Please choose one Male Female Other

Gender at Birth Please choose one Male Female Other

Address

City

State

Zip

Home Phone

Work Phone

Cell

Best Place To Reach You: Please choose one Home Work Cell

E-mail

Employer

Length of Employment

Martial Status Please choose one Single Married Widowed Divorced Partner Other

Spouses Name

Phone

Emergency Contact

Relationship

Phone

Do you have Medicare Insurance?

Do you have Medicaid Insurance?

TV Channel Name of Show Internet Mailer Physician Name of Dr. Patient their Name Radio Station Staff member Their Name

Primary Care Physician:

Phone

Current Specialist, if applicable:

Phone

How serious do you think your problem is?

What is/are your main problem(s)/symptom(s) prompting your request for a consultation with the Dr.?

Would You Consider This Problem... Please choose one MINIMAL (Annoying but causing NO limitations) SLIGHT (Tolerable but causing a little limitation) MODERATE (Sometimes tolerable but definitely causing limitations) SEVERE (Causing Significant limitations) EXTREME (Causing near constant (>80% of the time) limitations)

What are your other symptoms?

When did your symptoms begin?

In spite of the fact that you are not a doctor, you are in fact the person who knows more about your condition than anyone else.In your own words and in your own opinion what do you think the real problem is?

Please list all prescription medications, over the counter drugs, and supplements (vitamins) you are currently taking

Have you ever been diagnosed with an auto-immune thyroid condition? (Hashimoto’s Thyroiditis) Please choose one Yes No

When

Have you ever been diagnosed with a Thyroid problem? Please choose one Yes No

When?

What condition?

Have you ever been diagnosed with any other diseases? Please choose one Yes No

Dates:

Do you have a family history of any major illnesses/diseases? Please choose one Yes No

Please list them

Is there anything you have done outside of medical advice that improved your condition?

Have you been seen by any specialists for your condition/symptoms?

What are you hoping the Dr. tells you today?

Describe what you hope or think he might be able to do for you:

Describe what will be different in your life if you can finally be relieved of these problems.

Have you lost any time from work? Please choose one Yes No

How much time and what tasks have been limited?

Have you lost any time from your chores/tasks at home? Please choose one Yes No

How much time and what tasks have been limited?

Have you lost any time from your family? Please choose one Yes No

How much time and what tasks have been limited?

Have you lost any time from your leisure activities? (Hobbies, Travel, Sports, etc...) Please choose one Yes No

How much time and what tasks have been limited?

On a Scale of 0-10 (10 being the most motivation possible, 0 being no motivation at all) please rate your motivation toachieve your health goals.

Surgery #1

Surgery #2

Surgery #3

Surgery #4

Surgery #5

Surgery #6

Date

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