PARATHYROID PATIENT INTAKE FORM

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 NameLast Name
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email Address*
example@example.com
Date of Birth*

MonthDayYear
Date
Gender at Birth*
Last 4 Digits of Social Security Number*
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Medical History
Has a doctor diagnosed you with parathyroid disease?*

YesNo
If yes (parathyroid disease), name of doctor who diagnosed you:
Have you ever had surgery for parathyroid disease before (NOT thyroid surgery)?*

YesNo
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)*

YesNo
Have you ever had Roux-en-Y gastric bypass/duodenal switch/stomach ulcer surgery)? (NOT gastric BAND surgery)*

YesNo
Have you ever been treated with radioactive iodine (I-131) to destroy an overactive thyroid gland? (NOT iodine pill for a thyroid scan)*

YesNo
If yes (treated with radioactive iodine/I-131), how long ago?
Were you ever treated with radiation to your neck?*

YesNo
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?*

YesNo
Have you ever been on dialysis?*

YesNo
Are you currently on dialysis?*

YesNo
Have you ever had a kidney transplant?*

YesNo
If yes (kidney transplant), what year?
Do you have any IMMEDIATE family members with parathyroid disease (parent/sibling/child)?*

YesNo
How long have you had high blood calcium?*
Should be Empty:

PARATHYROID PATIENT INTAKE FORM

DEMOGRAPHIC INFORMATION

Medical History