Patient Information
- Full Name: _________________ Date of Birth: _________
- Address: _________________ Phone: ________________
- Email: _________________ Insurance: ________________
Chief Complaint
- Primary reason for visit: ________________________________
- Duration of symptoms: __________________________________
Endocrine History
Diabetes History
- Type: □ Type 1 □ Type 2 □ Gestational □ None
- Year diagnosed: ________
- Current treatment: ________________________________
- Latest HbA1c: ________ Date: ________
Thyroid History
- Previous diagnosis: □ Hypothyroid □ Hyperthyroid □ None
- Current medications: ________________________________
- Previous thyroid surgery: □ Yes □ No
Other Endocrine Conditions
- □ Osteoporosis
- □ Pituitary disorders
- □ Adrenal disorders
- □ Parathyroid disease
Family History
- Diabetes: □ Yes □ No Relation: ________
- Thyroid disease: □ Yes □ No Relation: ________
- Other endocrine disorders: ________________________
Current Medications
| Medication |
Dose |
Frequency |
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Lifestyle Factors
- Exercise frequency: ________________________________
- Diet type: ________________________________________
- Smoking status: □ Never □ Former □ Current
- Alcohol use: □ None □ Occasional □ Regular
Review of Systems
General
- □ Weight changes
- □ Fatigue
- □ Sleep changes
Metabolic
- □ Heat/cold intolerance
- □ Excessive thirst
- □ Frequent urination
Musculoskeletal
- □ Joint pain
- □ Muscle weakness
- □ Fractures
Previous Tests
Authorization
Signature: _________________ Date: _________