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 Name Last 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 *

Month Day Year
Date
Gender at Birth *
Last 4 Digits of Social Security Number *
Home Address *

Street Address

Street Address Line 2

City 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? *
Please verify that you are human *
Should be Empty:

PARATHYROID PATIENT INTAKE FORM

DEMOGRAPHIC INFORMATION

Medical History