PDF Thyroid Assessment Questionnaire - BioSymmetry The objective of this study was to develop and pretest a thyroid cancer specifi c HRQoL questionnaire that can be used in addition to the more general European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30). The growth hormone produced by the pituitary gland is known as _____. PDF OMB Control No. 2900-0781 Respondent Burden: 15 Minutes ... Thyroid Cancer Questionnaire Insurance Designers of Central Texas, LLC 12466 Los Indios Trail #100 Austin, TX 78729 Phone 512-257-9700 FAX 512-257-9701 policy for thyroid cancer in Japan by distributing a questionnaire to all physicians who participated in the 37th meeting of the Japanese Society of Thyroid Surgery. Few studies have evaluated these associations in relation to other, more aggressive histologic types or thyroid cancer-specific mortality. Acta Oncologica, 2013; 52: 447-454 ORIGINAL ARTICLE Development of a disease-specific health-related quality of life questionnaire (THYCA-QoL) for thyroid cancer survivors OLGA HUSSON1,2, HARM R. HAAK3, FLOORTJE MOLS1,2, GRARD A. NIEUWENHUIJZEN4, WILLY-ANNE NIEUWLAAT5, PETER H. REEMST6, DYDE A. HUYSMANS7, ARNO W. TOORIANS8 & LONNEKE V. VAN DE POLL-FRANSE1,2 Acta Oncol Downloaded from . 100 patients with TED were administered all three questionnaires on two occasions. PDF AXA AFFIN - Thyroid Questionnaire 02042020 It gets to the heart of whether you should be tested for thyroid dysregulation, even if your conventional doc has dismissed your concerns. Thyroid-Related Quality of Life Measure ThyPRO Has Good ... require lifelong thyroid hormone therapy (Figure 2. Materials and Methods Two hundred seventy-two patients who underwent thyroidectomy from January to December 2010 were recruited in this study. Yes / No 11. Thyroid Screening Questionnaire Patient Name_____ Date_____ Put a check by the following statements that apply to your family history, your personal history, and the symptoms that you may have. Brief overview of my results and what they mean This study demonstrates that the survey scores corres-pond with improvement in the thyroid blood tests. Thyroid Questionnaire #2 I love this questionnaire from Dr. Hotze, an integrative physician. I also like to use these questions to build a tracker for how you improve with Thyroid Assessment Questionnaire Do you currently have any of these symptoms? _____ Check all thyroid therapies you have received: Propylthiouracil (PTU) Tapazole Radioactive Iodine Thyroid hormone (Synthroid, Armour, etc.) Patient Prep (adult & pediatric): • Patient to complete a thyroid questionnaire upon arrival in Nuclear Medicine Department. The normal thyroid gland makes two thyroid hormones: T. 4. and triio-dothyronine (T. 3). Increasing Incidence of Thyroid Cancer (1973-2002) • 5 year survival for papillary thyroid cancer increased from 92.7% in 1974 to 97.4% in 2001 (p<.05). It results in accelerated tissue metabolism with multi-organ involvement ranging from cardiovascular to neuropsychological function. Symptoms Past History Date of onset of symptoms _____ Thyroid hormone (Synthroid) use . I love this questionnaire from Dr. Hotze, another integrative physician. Symptoms & Diagnosis What diagnoses has this patient received Baseline characteristics for the study participants are described in Table 1. Lovelace Medical Group, Division of Endocrinology Attention: Endocrinology 6701 Jefferson St NE, Albuquerque, NM 87109 Phone:505-727-6200 FAX: 505-727-7069 Importance Owing to the good prognosis of differentiated thyroid cancer (DTC), guidelines recommend total thyroidectomy (TT) or thyroid lobectomy (TL) as surgical treatment for DTC with low to intermediate risk of recurrence. It is the first specific questionnaire for patients with different thyroid diseases which was validated and standardized. Responsiveness has previously been demonstrated for a PRO developed specifically for patients with Graves' orbitopathy (the GO-QOL questionnaire) , but the present study is the first to evaluate the responsiveness of a QoL instrument in the most common thyroid diseases, ie, patients with hyperthyroidism, hypothyroidism, and goiter. Thyroid Questionnaire By Sara Gottfried, MD | September 30, 2013. Thyroid Questionnaire My risk factors for hypothyroidism include: ____ I have a family history of thyroid disease ____ I have had my thyroid "monitored" in the past to watch for changes ____ I had a previous diagnosis of goiters/nodules ____ I currently have a goiter ____ I was treated for hypothyroidism in the past . NAME OF PATIENT/VETERAN PATIENT/VETERAN'S SOCIAL SECURITY NUMBER. Material and methods. OMB #: 0925-0406 Expiration Date: 11/30/2005. The questionnaire included questions about therapeutic policies for well-differentiated thyroid cancer, principally according to the clinical stage and HOWEVER • The rates of distant metastases in men increased from 4% to 9%. Date of last menstrual period: _____ 2. thyroid gland is usually enlarged (goiter) and has a decreased ability to make thyroid hormones. ThyPRO is a thyroid-specific quality of life (QoL) questionnaire applicable to patients with benign thyroid disorders. b) Subjects have completed a written informed consent. How long have you had a thyroid problem? 3. If yes, what type: Xray IVP Gallbladder Myelogram Angiogram CT-Scan 3. Palpitations (rapid or forceful heart beat) ☐Yes No Poor concentration ☐Yes ☐No Memory Loss ☐Yes No Difficulty sleeping ☐Yes No Excessive need for sleep ☐Yes ☐No Fatigue ☐Yes ☐No the Thyroid Dysfunction Questionnaire (TDQ), which is a tool to measure thyroid dysfunction mainly for women of reproductive age (Mutalazimah, et al. Page 2 of 2 10. It is therefore important to enquire about personal and family medical history to establish thyroid dysfunction. Do you suffer from any other heath condition/ Graves' disease is the most common cause of hyperthyroidism. It gets to the heart of whether you should be tested for thyroid dysregulation, even if your conventional doc has dismissed your concerns. Background: Greater height and body mass index (BMI) have been associated with an increased risk of thyroid cancer, particularly papillary carcinoma, the most common and least aggressive subtype. Age: Did you have surgery for your thyroid cancer? It gets to the heart of whether you should be tested for thyroid dysregulation, even if your conventional doc has dismissed your concerns. Fatigue, loss of energy, or sleeping more than average. I also like to use these questions to build a tracker for how you improve with Use of thyroid hormones in hypothyroid and euthyroid patients: a 2020 THESIS questionnaire survey of members of the Danish Endocrine Society J Endocrinol Invest ( 2021 ) , pp. Neck Surgery Other (explain) Are you experiencing any of the following? ___ Papillary thyroid cancer ___ Follicular thyroid cancer ___ Medullary thyroid cancer ( ___ Sporadic ___ Isolated familial medullary) ___ Anaplastic carcinoma ___ Thyroid lymphoma 4. If yes, please give details. Thyroid-Specific Patient-Reported Outcome Measure (ThyPRO), Table 2 Number of problems identified within each of six rounds of cognitive interviews (Adapted from Watt et al. This results in a negative impact on the quality of life (QOL) of the individual patient. Follow-up Health Questionnaire. Endocrine Diseases Disability Benefits Questionnaire Released March 2021. Have you had any of the following: 10. a) Heart or circulatory problem If yes, please give details. Medical History Questionnaire No Past Medical History Acne Acute Myocardial Infarction (Heart Attack) Anemia (Low Blood Count) Anxiety (Bowel Movement)Arthritis Asthma Autoimmune Disorder (Lupus/Scleroderma) Benign Polyps of The Large Intestine (Colon Polyps) Benign Prostatic Hypertrophy (Enlarged Prostate) 2. does the veteran have or has he or she ever had a thyroid or parathyroid condition? Background: Thyroid diseases are very common in our country and influence the quality of life of patients . THYROID AND PARATHYROID CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE For Internal VA Use Thyroid and Parathyroid Disability Benefits Questionnaire Page 1 of 8 ACCEPTABLE CLINICAL EVIDENCE (ACE) INDICATE METHOD USED TO OBTAIN MEDICAL INFORMATION TO COMPLETE THIS DOCUMENT: A) parathyroid hormone B) aldosterone C) calcitonin D) thyroid hormone 17. DUTY OF DISCLOSURE Before you enter into or become insured under an insurance contract with us, you and any life to be insured are required under the Insurance Contracts Act 1984 to provide us with the information we need to decide whether we'll accept . P C P C P C Depression Cold hands and feet Fatigue Dry skin Yellow or orange skin Body Temp below 97.7° . Please read each item carefully and check only those factors that apply to you. 2. questionnaire 4months after anti-thyroid medications to gauge the responsiveness of the survey. CLINICAL STUDY Validity and reliabilityof the novel thyroid-specific qualityof life questionnaire, ThyPRO Torquil Watt1,2, Laszlo Hegedu¨s3, Mogens Groenvold2,4, Jakob Bue Bjorner2,5,A˚ se Krogh Rasmussen1, Steen Joop Bonnema3 and Ulla Feldt-Rasmussen1 1Department of Endocrinology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark, 2Institute of Public THYROID QUESTIONNAIRE | PAGE 1 OF 5 Please complete the questionnaire and return to TAL. Results: Thyroid cancer was diagnosed in 16 women (11.4%) and 2 men (1.4%), at 17-41 years and 39-57 years of age, respectively. Background: Thyroid diseases are very common in our country and influence the quality of life of patients . NAME OF PATIENT/VETERAN PATIENT/VETERAN'S SOCIAL SECURITY NUMBER. that affect thyroid cancer survivors. Purpose To clarify the current trends in TSH suppression therapy for Japanese papillary carcinoma patents, a questionnaire survey was conducted among hospitals employing councilors of the Japanese Society of Thyroid Surgery. NHANES III. Thyroid Questionnaire - 3.3 . General symptoms in this questionnaire can also be caused by other conditions. Methods The questionnaire consisted of 11 clinical questions divided into two sections. 3. Thyroid Questionnaire We thank you for applying for an HDFC Standard Life Insurance Policy. A) somatotropin B) prolactin C) luteinizing hormone D) follicle-stimulating hormone 16. _____ What did it show? Thyroid hormone helps the body use energy, stay warm and keep the brain, heart, muscles, and other organs working as they should. Yes / No 10. b) Visual defect due to thyroidism. Heart disease Thyroid disease Diabetes Sinus disease Stroke Seizure Eye inflammation Mononucleosis Hepatitis B or C Tuberculosis Kidney disease Kidney stones Blood in urine Pleurisy Pneumonia Asthma Blood clots Pulmonary hypertension Heart failure Fluid on the lungs Weight loss BMS508 - Health Questionnaire 03/23/2021 Health Questionnaire Name: _____ Date of Birth: Preferred Pharmacy: Location: Past Medical History Please checkmark if you now have or have ever had any of the following medical problems listed These oversampled groups included children aged 2 months to 5 years, persons over age 60, Mexican-American persons, and non-Hispanic black persons. Results One hundred and seventy-two questionnaires were mailed, and 89 hospitals . 1a. Hashimoto's is an autoimmune disease in which the body's immune system inappropriately attacks the thyroid tissue. Microsoft Word - AXA AFFIN - Thyroid Questionnaire_02042020 Author: ivie_ojingkil Created Date: 4/2/2020 4:36:49 PM . 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thyroid questionnaire pdf

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PDF Thyroid Assessment Questionnaire - BioSymmetry The objective of this study was to develop and pretest a thyroid cancer specifi c HRQoL questionnaire that can be used in addition to the more general European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30). The growth hormone produced by the pituitary gland is known as _____. PDF OMB Control No. 2900-0781 Respondent Burden: 15 Minutes ... Thyroid Cancer Questionnaire Insurance Designers of Central Texas, LLC 12466 Los Indios Trail #100 Austin, TX 78729 Phone 512-257-9700 FAX 512-257-9701 policy for thyroid cancer in Japan by distributing a questionnaire to all physicians who participated in the 37th meeting of the Japanese Society of Thyroid Surgery. Few studies have evaluated these associations in relation to other, more aggressive histologic types or thyroid cancer-specific mortality. Acta Oncologica, 2013; 52: 447-454 ORIGINAL ARTICLE Development of a disease-specific health-related quality of life questionnaire (THYCA-QoL) for thyroid cancer survivors OLGA HUSSON1,2, HARM R. HAAK3, FLOORTJE MOLS1,2, GRARD A. NIEUWENHUIJZEN4, WILLY-ANNE NIEUWLAAT5, PETER H. REEMST6, DYDE A. HUYSMANS7, ARNO W. TOORIANS8 & LONNEKE V. VAN DE POLL-FRANSE1,2 Acta Oncol Downloaded from . 100 patients with TED were administered all three questionnaires on two occasions. PDF AXA AFFIN - Thyroid Questionnaire 02042020 It gets to the heart of whether you should be tested for thyroid dysregulation, even if your conventional doc has dismissed your concerns. Thyroid-Related Quality of Life Measure ThyPRO Has Good ... require lifelong thyroid hormone therapy (Figure 2. Materials and Methods Two hundred seventy-two patients who underwent thyroidectomy from January to December 2010 were recruited in this study. Yes / No 11. Thyroid Screening Questionnaire Patient Name_____ Date_____ Put a check by the following statements that apply to your family history, your personal history, and the symptoms that you may have. Brief overview of my results and what they mean This study demonstrates that the survey scores corres-pond with improvement in the thyroid blood tests. Thyroid Questionnaire #2 I love this questionnaire from Dr. Hotze, an integrative physician. I also like to use these questions to build a tracker for how you improve with Thyroid Assessment Questionnaire Do you currently have any of these symptoms? _____ Check all thyroid therapies you have received: Propylthiouracil (PTU) Tapazole Radioactive Iodine Thyroid hormone (Synthroid, Armour, etc.) Patient Prep (adult & pediatric): • Patient to complete a thyroid questionnaire upon arrival in Nuclear Medicine Department. The normal thyroid gland makes two thyroid hormones: T. 4. and triio-dothyronine (T. 3). Increasing Incidence of Thyroid Cancer (1973-2002) • 5 year survival for papillary thyroid cancer increased from 92.7% in 1974 to 97.4% in 2001 (p<.05). It results in accelerated tissue metabolism with multi-organ involvement ranging from cardiovascular to neuropsychological function. Symptoms Past History Date of onset of symptoms _____ Thyroid hormone (Synthroid) use . I love this questionnaire from Dr. Hotze, another integrative physician. Symptoms & Diagnosis What diagnoses has this patient received Baseline characteristics for the study participants are described in Table 1. Lovelace Medical Group, Division of Endocrinology Attention: Endocrinology 6701 Jefferson St NE, Albuquerque, NM 87109 Phone:505-727-6200 FAX: 505-727-7069 Importance Owing to the good prognosis of differentiated thyroid cancer (DTC), guidelines recommend total thyroidectomy (TT) or thyroid lobectomy (TL) as surgical treatment for DTC with low to intermediate risk of recurrence. It is the first specific questionnaire for patients with different thyroid diseases which was validated and standardized. Responsiveness has previously been demonstrated for a PRO developed specifically for patients with Graves' orbitopathy (the GO-QOL questionnaire) , but the present study is the first to evaluate the responsiveness of a QoL instrument in the most common thyroid diseases, ie, patients with hyperthyroidism, hypothyroidism, and goiter. Thyroid Questionnaire By Sara Gottfried, MD | September 30, 2013. Thyroid Questionnaire My risk factors for hypothyroidism include: ____ I have a family history of thyroid disease ____ I have had my thyroid "monitored" in the past to watch for changes ____ I had a previous diagnosis of goiters/nodules ____ I currently have a goiter ____ I was treated for hypothyroidism in the past . NAME OF PATIENT/VETERAN PATIENT/VETERAN'S SOCIAL SECURITY NUMBER. Material and methods. OMB #: 0925-0406 Expiration Date: 11/30/2005. The questionnaire included questions about therapeutic policies for well-differentiated thyroid cancer, principally according to the clinical stage and HOWEVER • The rates of distant metastases in men increased from 4% to 9%. Date of last menstrual period: _____ 2. thyroid gland is usually enlarged (goiter) and has a decreased ability to make thyroid hormones. ThyPRO is a thyroid-specific quality of life (QoL) questionnaire applicable to patients with benign thyroid disorders. b) Subjects have completed a written informed consent. How long have you had a thyroid problem? 3. If yes, what type: Xray IVP Gallbladder Myelogram Angiogram CT-Scan 3. Palpitations (rapid or forceful heart beat) ☐Yes No Poor concentration ☐Yes ☐No Memory Loss ☐Yes No Difficulty sleeping ☐Yes No Excessive need for sleep ☐Yes ☐No Fatigue ☐Yes ☐No the Thyroid Dysfunction Questionnaire (TDQ), which is a tool to measure thyroid dysfunction mainly for women of reproductive age (Mutalazimah, et al. Page 2 of 2 10. It is therefore important to enquire about personal and family medical history to establish thyroid dysfunction. Do you suffer from any other heath condition/ Graves' disease is the most common cause of hyperthyroidism. It gets to the heart of whether you should be tested for thyroid dysregulation, even if your conventional doc has dismissed your concerns. Background: Greater height and body mass index (BMI) have been associated with an increased risk of thyroid cancer, particularly papillary carcinoma, the most common and least aggressive subtype. Age: Did you have surgery for your thyroid cancer? It gets to the heart of whether you should be tested for thyroid dysregulation, even if your conventional doc has dismissed your concerns. Fatigue, loss of energy, or sleeping more than average. I also like to use these questions to build a tracker for how you improve with Use of thyroid hormones in hypothyroid and euthyroid patients: a 2020 THESIS questionnaire survey of members of the Danish Endocrine Society J Endocrinol Invest ( 2021 ) , pp. Neck Surgery Other (explain) Are you experiencing any of the following? ___ Papillary thyroid cancer ___ Follicular thyroid cancer ___ Medullary thyroid cancer ( ___ Sporadic ___ Isolated familial medullary) ___ Anaplastic carcinoma ___ Thyroid lymphoma 4. If yes, please give details. Thyroid-Specific Patient-Reported Outcome Measure (ThyPRO), Table 2 Number of problems identified within each of six rounds of cognitive interviews (Adapted from Watt et al. This results in a negative impact on the quality of life (QOL) of the individual patient. Follow-up Health Questionnaire. Endocrine Diseases Disability Benefits Questionnaire Released March 2021. Have you had any of the following: 10. a) Heart or circulatory problem If yes, please give details. Medical History Questionnaire No Past Medical History Acne Acute Myocardial Infarction (Heart Attack) Anemia (Low Blood Count) Anxiety (Bowel Movement)Arthritis Asthma Autoimmune Disorder (Lupus/Scleroderma) Benign Polyps of The Large Intestine (Colon Polyps) Benign Prostatic Hypertrophy (Enlarged Prostate) 2. does the veteran have or has he or she ever had a thyroid or parathyroid condition? Background: Thyroid diseases are very common in our country and influence the quality of life of patients . THYROID AND PARATHYROID CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE For Internal VA Use Thyroid and Parathyroid Disability Benefits Questionnaire Page 1 of 8 ACCEPTABLE CLINICAL EVIDENCE (ACE) INDICATE METHOD USED TO OBTAIN MEDICAL INFORMATION TO COMPLETE THIS DOCUMENT: A) parathyroid hormone B) aldosterone C) calcitonin D) thyroid hormone 17. DUTY OF DISCLOSURE Before you enter into or become insured under an insurance contract with us, you and any life to be insured are required under the Insurance Contracts Act 1984 to provide us with the information we need to decide whether we'll accept . P C P C P C Depression Cold hands and feet Fatigue Dry skin Yellow or orange skin Body Temp below 97.7° . Please read each item carefully and check only those factors that apply to you. 2. questionnaire 4months after anti-thyroid medications to gauge the responsiveness of the survey. CLINICAL STUDY Validity and reliabilityof the novel thyroid-specific qualityof life questionnaire, ThyPRO Torquil Watt1,2, Laszlo Hegedu¨s3, Mogens Groenvold2,4, Jakob Bue Bjorner2,5,A˚ se Krogh Rasmussen1, Steen Joop Bonnema3 and Ulla Feldt-Rasmussen1 1Department of Endocrinology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark, 2Institute of Public THYROID QUESTIONNAIRE | PAGE 1 OF 5 Please complete the questionnaire and return to TAL. Results: Thyroid cancer was diagnosed in 16 women (11.4%) and 2 men (1.4%), at 17-41 years and 39-57 years of age, respectively. Background: Thyroid diseases are very common in our country and influence the quality of life of patients . NAME OF PATIENT/VETERAN PATIENT/VETERAN'S SOCIAL SECURITY NUMBER. that affect thyroid cancer survivors. Purpose To clarify the current trends in TSH suppression therapy for Japanese papillary carcinoma patents, a questionnaire survey was conducted among hospitals employing councilors of the Japanese Society of Thyroid Surgery. NHANES III. Thyroid Questionnaire - 3.3 . General symptoms in this questionnaire can also be caused by other conditions. Methods The questionnaire consisted of 11 clinical questions divided into two sections. 3. Thyroid Questionnaire We thank you for applying for an HDFC Standard Life Insurance Policy. A) somatotropin B) prolactin C) luteinizing hormone D) follicle-stimulating hormone 16. _____ What did it show? Thyroid hormone helps the body use energy, stay warm and keep the brain, heart, muscles, and other organs working as they should. Yes / No 10. b) Visual defect due to thyroidism. Heart disease Thyroid disease Diabetes Sinus disease Stroke Seizure Eye inflammation Mononucleosis Hepatitis B or C Tuberculosis Kidney disease Kidney stones Blood in urine Pleurisy Pneumonia Asthma Blood clots Pulmonary hypertension Heart failure Fluid on the lungs Weight loss BMS508 - Health Questionnaire 03/23/2021 Health Questionnaire Name: _____ Date of Birth: Preferred Pharmacy: Location: Past Medical History Please checkmark if you now have or have ever had any of the following medical problems listed These oversampled groups included children aged 2 months to 5 years, persons over age 60, Mexican-American persons, and non-Hispanic black persons. Results One hundred and seventy-two questionnaires were mailed, and 89 hospitals . 1a. Hashimoto's is an autoimmune disease in which the body's immune system inappropriately attacks the thyroid tissue. Microsoft Word - AXA AFFIN - Thyroid Questionnaire_02042020 Author: ivie_ojingkil Created Date: 4/2/2020 4:36:49 PM .

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thyroid questionnaire pdf