Patient (Your) Full Name
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First Name
Last Name
Contact Email
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Contact Phone Number
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Assigned Sex At Birth
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Male
Female
Pronouns
He/Him/His
She/Her/Hers
Age
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Birth Date
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Month
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Day
Year
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Your referring provider (e.g. endocrinologist/PCP)? If none, type & select "none"
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Your referring provider name (e.g. endocrinologist/PCP)? If none, type "none"
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Your referring provider phone number
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List your other providers. If you have a cardiologist or pulmonologist, please list
Are you interested in (check all that apply)?
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Consultation - In-person
Virtual/Second Opinion Consultation
Diagnostic Evaluation
Treatment or Intervention
Are you concerned about
Please Select
1) Thyroid
2) Parathyroid
3) Adrenal
What is your current thyroid diagnosis (check all that apply)?
Thyroid nodule/goiter
Thyroid cancer
Hyperthyroidism
Hypothyroidism
Graves' disease
Hashimotos autoimmune thyroiditis
Other or Not Sure
What exams were done (check all that apply)?
Thyroid ultrasound
FNA "fine needle aspiration" biopsy
Thyroid function test (lab)
Autoimmune antibody test (lab)
Thyroid uptake scan (for hyperthyroidism)
Other or Not sure
Do you have the following conditions (check all that apply)?
Elevated calcium level (blood or urine)
Elevated parathyroid hormone (PTH)
Not sure
What imaging studies have you done (check all that apply)?
None or Not sure
Neck ultrasound
Parathyroid (sestamibi) scan
Bone Density scan (DEXA)
Neck CT or MRI
What is your symptoms related to high calcium and hyperparathyroidism (check all that apply)?
None
Fatigue
Anxiety/Irritability
Joint and muscle aches
Muscle weakness
Abdominal pain
Constipation
Frequent thirst/urination
Poor memory & concentration "brain fog"
Heartburns/reflux
Do you have these conditions (check all that apply)?
None
Kidney stone(s)
Low bone density (osteopenia or osteoporosis)
Bone Fractures
Hypertension
Other
What is your diagnosis (check all that apply)?
Adrenal tumor/mass
Conn Syndrome (hyperaldosteronism)
Cushing Syndrome (hypercortisolism)
Pheochromocytoma
Other or Not sure
What imaging study have you done?
Abdominal CT scan
Abdominal MRI
None or not sure
Other
Describe your main concerns and any symptoms specifically related to your condition
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How did you hear about American Endocrine & Dr. Suh?
Doctor's referral
Search engine (e.g. Google)
Social media
Online forum (e.g. Reddit)
A directory of doctors (e.g. insurance)
Patient recommendation
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