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,
Form is listed at the bottom of the menu column on the far left of the home page.


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