Thyroid Disorders

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Patient Information

Full Name *

Age *

Gender *

Weight (kg)

If you have any other complaints, please describe them

Reason for Application

What thyroid diagnosis led you to apply to our council?

Graves' Disease (Toxic Goitre / Hyperthyroidism)

Hypothyroidism (Underactive Thyroid / Hashimoto's Thyroiditis)

Thyroiditis (subacute thyroiditis, silent thyroiditis, etc.)

Thyroid Cancer (papillary, follicular, medullary, anaplastic, etc.)

Nodular Goitre / Suspicious Thyroid Nodule

Other

Current Blood Test Results

Date

TSH

Free T3

Free T4

Anti-TPO

Anti-Tg

TSH Receptor Antibody (TRAb)

Calcitonin / Thyroglobulin

General Health History and Lifestyle

Medications and Supplements You Take Regularly

Other chronic conditions (diabetes, hypertension, heart disease, etc.)

Is there a family history of thyroid disease or cancer?

Yes

I don't know

Details

Your Smoking and Alcohol Use

For Female Patients: Do you have a pregnancy plan, a current pregnancy or a history of breastfeeding?

Your Questions for the Council

Question 1

Question 2

Question 3

Treatment Preference

What treatment approach would you prefer?

I have read and understood the Information and Consent Text regarding the Provision of Remote Healthcare Services and hereby accept its terms.*

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Thyroid Disorders