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Vitamin D Deficiency

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/Conditions
/Vitamin D Deficiency
/Application Form

Vitamin D Deficiency

Please fill in the form completely.

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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 is the main reason for applying to our council?

Chronic and Resistant Vitamin D Deficiency / Insufficiency

25-OH Vitamin D Level Not Rising Despite High-Dose Supplements

Raised Parathyroid Hormone due to Vitamin D Deficiency (Secondary Hyperparathyroidism)

Chronic Fatigue, Widespread Muscle and Joint Pain, and Metabolic Findings

Malabsorption or a History of Digestive System Surgery

Other / Preventive Consultation

Other

Medical History

When was low vitamin D first detected?

Which vitamin D preparations and doses have you used so far?

What complaints do you currently have?

Widespread body pain, bone and muscle aches

Chronic fatigue, weakness and low energy

Muscle weakness (especially difficulty climbing stairs or standing up)

Hair loss and brittle nails

Mood swings, anxiety or depressed mood

Frequent illness / low immunity

Other

Your sun exposure and lifestyle

Latest Blood Test Results

Date

25-OH Vitamin D Total

Serum Calcium (Ca)

Phosphate (P)

Parathyroid Hormone (PTH)

Alkaline Phosphatase (ALP)

Liver and Kidney Function Tests (Creatinine, ALT, AST)

Digestive System and Medications

Do you have a digestive or gastrointestinal disease? (coeliac disease, Crohn's disease, IBS, stomach surgery, etc.)

Yes

Details

Other medications or stomach protectors you take regularly

Your Questions for the Council

Question 1

Question 2

Question 3

Tests and Reports

No tests

Blood Tests (25-OH Vitamin D, PTH, Calcium, Phosphate)

Bone Densitometry (DEXA)

Other Test Results

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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