THYROID STATUS REPORT from _____________________________________ Date: ________________
You can reach me at phone # _________________ at time: ____________.
Current thyroid medicine(s): __________________________________________________________________
Prior thyroid dose: __________________________________________________________________________
(Please indicate how much you take and when, and for how long you?ve been on this dose.)
What symptoms are improved with the current dose? _______________________________________________
What symptoms are not changed? ______________________________________________________________
Any signs or symptoms of overdose? ____________________________________________________________
Is the current dose better or worse than the prior dose? _____________________________________________
Are you happy with the current dose? ___________________________________________________________
How much medicine do you have left? (# of pills of each dose) _______________________________________
Your pharmacy phone # ________________ Do you need one month at a time? __________
If available, what is your current weight? _______________ BP______________ Average Pulse____________
Other info? _________________________________________________________________
Fax to Donna Hurlock, MD at 703-823-5873 or mail to 205 S. Whiting Street, Suite 303.
Alexandria, VA. 22304.
Expect a response by phone or fax within 24 hours, excluding weekends and holidays.
Copies of this form can also be downloaded from my website, www.dhurlock.yourmd.com.
Form is listed at the bottom of the menu column on the far left of the home page.