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.

* denotes mandatory fields

Demographic Information

First Name *(Required)

Last Name *(Required)

Date of Birth *(Required)

Month

Day

Year

Gender at Birth *(Required)

Cell Phone

Home Phone

Email Address *(Required)

Home Address *(Required)

Medical History

1) Has a doctor diagnosed you with parathyroid disease? *(Required)

2) If yes (parathyroid disease), name of doctor who diagnosed you:

3) Have you ever had surgery for parathyroid disease before (NOT thyroid surgery)? *(Required)

4) If yes (parathyroid surgery), how long ago?

5) 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) *(Required)

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

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

8) If yes (treated with radioactive iodine/I-131), how long ago?

9) Were you ever treated with radiation to your neck? *(Required)

10) If yes (treated with radiation), how long ago?

11) If yes (treated with radiation), Reason: Acne/Tonsillitis/Enlarged newborn thymus/Cancer of neck

12) Do you have decreased kidney function? *(Required)

13) Have you ever been on dialysis? *(Required)

14) Are you currently on dialysis? *(Required)

15) Have you ever had a kidney transplant? *(Required)

16) If yes (kidney transplant), what year?

17) Do you have any IMMEDIATE family members with parathyroid disease (parent/sibling/child)? *(Required)

18) How long have you had high blood calcium? *(Required)

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