PARATHYROID PATIENT INTAKE FORM
Please fill out the form below and submit when completed. After reviewing your submission, a member of our team will call you on next steps. If you prefer, you may call our office directly at (813) 844-8335.
DEMOGRAPHIC INFORMATION
Name
*
First Name
Last Name
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Date
Gender at Birth
*
Last 4 Digits of Social Security Number
*
Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Medical History
Has a doctor diagnosed you with parathyroid disease?
*
Yes
No
If yes (parathyroid disease), name of doctor who diagnosed you:
Have you ever had surgery for parathyroid disease before (NOT thyroid surgery)?
*
Yes
No
If yes (parathyroid surgery), how long ago?
Have you ever had any other surgery in your neck? (Thyroid/Tracheostomy/Mediastinoscopy/Carotid artery/Cervical spine surgery/Neck dissection for cancer or lymph node removal)
*
Yes
No
Have you ever had Roux-en-Y gastric bypass/duodenal switch/stomach ulcer surgery)? (NOT gastric BAND surgery)
*
Yes
No
Have you ever been treated with radioactive iodine (I-131) to destroy an overactive thyroid gland? (NOT iodine pill for a thyroid scan)
*
Yes
No
If yes (treated with radioactive iodine/I-131), how long ago?
Were you ever treated with radiation to your neck?
*
Yes
No
If yes (treated with radiation), how long ago?
If yes (treated with radiation), Reason: Acne/Tonsillitis/Enlarged newborn thymus/Cancer of neck
Do you have decreased kidney function?
*
Yes
No
Have you ever been on dialysis?
*
Yes
No
Are you currently on dialysis?
*
Yes
No
Have you ever had a kidney transplant?
*
Yes
No
If yes (kidney transplant), what year?
Do you have any IMMEDIATE family members with parathyroid disease (parent/sibling/child)?
*
Yes
No
How long have you had high blood calcium?
*
How did you hear about our program?
SUBMIT
Should be Empty: