Parathyroid Patient Screening 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)

Preferred name/nickname

DOB *(Required)

Month

Day

Year

Gender at birth *(Required)

Height *(Required)

Weight *(Required)

Home phone

Cell phone

Email address *(Required)

Preferences

Preferred language

Other languages spoken

How do you prefer to have your consultation with our doctors? *(Required)

What phone number is best for our doctors to use for your consultation? *(Required)

How did you learn of us? *(Required)

Medical History

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

1A) If yes (parathyroid disease), name of doctor who diagnosed you: *(Required)

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

2A) If yes (parathyroid surgery), how long ago? *(Required)

3) 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)

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

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

5A) If yes (treated with radioactive iodine/I-131), how long ago? *(Required)

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

6A) If yes (treated with radiation), how long ago? *(Required)

6B) If yes (treated with radiation), Reason: Acne/Tonsillitis/Enlarged newborn thymus/Cancer of neck *(Required)

7) Have you ever taken lithium for more than one year continuously? *(Required)

7A) Are you still taking lithium? *(Required)

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

9) Do you take thyroid hormone? *(Required)

9A) If yes (take thyroid hormone), for how long? *(Required)

9B) If yes (take thyroid hormone), what is your current dose? *(Required)

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

10A) Are you currently on dialysis? *(Required)