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					                  Thyroid Nodule Patient Questionaire


Name: __________________________________ Date: ___________________


Contact: ________________________________



Have you had any problems with any of the following:


 Pain or tenderness in the front of        Consistently feeling warmer than
  your neck                                  others
 Swelling in the front of your neck        Insomnia
 Difficulty Swallowing                     More than one bowl movement
                                             per day
 Painful Swallowing
                                            Unexplained anxiety
 Hoarseness for more than 2
  weeks                                     Consistently feeling colder than
                                             others
 Cough for more than one month
                                            Chest pain
 Coughing up blood
                                            Weight gain without explanation
 Shortness of breath
                                            Constipation
 Bone pain
                                            Dry Skin
 Weakness of an arm of leg
                                            Muscle cramps
 Numbness of an arm or leg
                                            Slowed thinking
 Unable to control urination or
  bowel movements                           Poor memory
 Hand trembling                            Depressed mood
 Palpitations (heart beating hard,         Flushing
  fast or irregularly)
                                            Diarrhea
 Unexplained weight loss




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Johns Hopkins Template
                         Thyroid Nodule Questionaire

Do you know of any family members with a history of:
    High calcium level in the blood
    Kidney stones
    Hyperparathyroidism
    High blood pressure that is severe, poorly controlled, or bounces around
    Adrenal gland tumor
    Pheochromocytoma
    Radiation treatments in childhood (for tonsillitis or acne)



Please list any other medical conditions for which you are being followed:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________




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