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									                         Patient Self-Report History

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



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o Muscle cramps
o Slowed thinking
o Poor memory
o Depressed mood.
After receiving the recombinant TSH (Thyrogen(R)) injections, did you have…


o Nausea
o Headache
o Other symptoms. If so, specify:
   ____________________________________________________________




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




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