Pre-Consult Patient Questionnaire
Paul is offering 1-1 coaching/consults on thyroid hormone use and hypothyroidism and adrenal disorders.
This is an OPTIONAL questionnaire that you may or may not feel is helpful. It will at least prompt some thoughts on relevant information that will make any coaching session more productive.
Using this quesitonnaire is completely OPTIONAL and you may have a better format for sending Paul information prior to a coaching session.
If you decide to send Paul any information prior to a coaching session then PLEASE try to send only ONE EMAIL with all the information contained within it, rather than several emails with several attachments.
Here is the text of a Pre-Consult Patient Questionnaire ( have also included this as a .PDF file which you could copy and paste into an email editor):
PRE-CONSULT PATIENT QUESTIONNAIRE
This is your medical history form, in complex cases it may need to be completed prior to your first proper session. All information will be kept confidential. Please try to make it as accurate and complete as possible.
Please email the completed form back to email@example.com.
Note: I would need to have this questionnaire emailed to me at least 5 working days prior to a coaching session.
Please feel free to add new lines and extra spacing where you need to.
Date questionnaire was completed:
Any children (Y/N)?
If Y then please state how many and their ages:
If female then are you still having monthly cycles:
SIGNIFICANT CHILDHOOD/ADULT ILLNESSES/OPERATIONS:
Please list any significant illnesses you had as a child or adult that might be relevant:
Please list any significant operations or surgical procedure that might be relevant:
RELEVANT FAMILY MEDICAL HISTORY/ILLNESSES:
Please list any family medical history (father, mother, siblings) that you feel may be relevant to you:
CURRENT MEDICATIONS THAT YOU TAKE - PLEASE LIST ALL AND THEIR DOSE SIZES AND WHEN YOU TAKE THEM:
HISTORY OF THYROID / ADRENAL PROBLEMS:
Did any events precede the start of this/these issues (if so then please explain):
How did you first become aware of the problem(s):
What was the original diagnosis:
Approximate date of original diagnosis:
Who diagnosed it:
How was it diagnosed:
Please state the detailed lab test results used for the original diagnosis with specific result, lab reference range and units of the test result (e.g. nmol/L):
PLEASE DESCRIBE THE PROGRESSION OF THE ILLNESS FROM THE TIME IT WAS DIAGNOSED UNTIL NOW:
Use your own words and please provide any relevant lab test results that were obtained along the way:
CURRENT SITUATION/SYMPTOMS AND TREATMENT:
As well as describing your current symptoms and how the thyroid/adrenal issue(s) are affecting you please also include the details of the specific medications being used to treat the condition with their dose sizes and units (e.g. mcg), and what time(s) of the day you take these:
SPECIFIC LABORATORY TESTS YOU HAVE HAD:
If you have had any of these then please provide the:
What thyroid or other relevant medication you were on when the test was completed:
The specific results with the laboratory test result/value, units of measurement and the lab reference range for the test result (not just 'normal' or 'ok'):
Any doctor/personal physician comment on the result at the time:
Laboratory Test Results:
1) Full Thyroid Panel: TSH, FT4, FT3, rT3, Hashimoto's Autoantibodies: TPO and Tg:
2) 8am Morning Cortisol Test:
3) Synacthen Test (also known as ACTH Stimulation Test):|
4) Adrenal Saliva Test (please provide results for each sample with the reference range for the sample, and the units of measurement):
5) B12 and prior to the test when you had last taken any supplement that contained any B12:
6) Vitamin D:
7) Full Iron Panel: serum iron, serum ferritin, total iron binding capacity and transferrin saturation %
8) Other Laboratory Tests Results that You Believe are Relevant:
VITALS (ALSO REFERRED TO AS 'SIGNS'):
If you have a home oral thermometer and a home blood pressure meter then this information can be extremely helpful - often more than thyroid laboratory test results. If you can provide one day of these it would be insightful. If you can't right now then these could be done at a later stage.
It is extremely helpful for a thyroid patient to record vitals and symptoms regularly, and in an organised way. How this information is presented makes a great deal of difference to how easy it is to interpret.
Vitals may be used to guide/coach people who need to adjust their thyroid medication. It is especially critical to use vitals when someone is using T3-only thyroid hormone therapy.
Vitals include body temperature, heart rate and blood pressure (BP). It is important to take them correctly!
For someone using T3-only (T3 monotherapy) it is very helpful to see your Basal temperature (waking), BP and heart rate on waking (or at least within the first 30 minutes of getting up). Then from that point on vitals should be taken just before each daytime T3 dose (30 minutes before is acceptable), 2-3 hours after each daytime T3 dose and then once in the evening. Sometimes it is necessary to take many more measurements before and after a T3 dose in order to determine what might be going on.
Use an oral thermometer. If you are using Geratherm thermometer hold for 5 to 8 minutes in the mouth. If you are using a Basal digital (the only digital I can recommend) hold it in your mouth 30 seconds longer than the beeps to signal it is "done". Take you HR and BP after having been seated and resting for 10 minutes and not within an hour of exercise. Place your feet flat on the floor and rest your arm at a 90-degree angle on a table so it is relaxed.
Here is a good example of well-organised thyroid information from a patient:
*** START EXAMPLE ***
DATE: 8th March 2011
Date any T4/NDT Meds were Last Taken: 7 weeks.
Other Relevant Medication and Doses: (e.g. HC, anti-depressants, etc.)
Get Up Time: 7:00 am.
25mcg T3@07:00 12.5mcg T3@11:00 12.5mcg T3@14:00 12.5mcg T3@17:00
TIME TEMP HR BP
07:30: 36.7, 95, 107/64
10:00: 36.8, 97, 101/65
12:00: 36.8, 92, 105/63
13:40: 37.0, 97, 109/65
15:50: 37.0, 94, 109/66
18:00: 37.0, 92, 106/63
Tired in the morning with headache. Didn't sleep well previous night. Felt warm from 12 noon & a bit on edge in the afternoon. Had energy in the afternoon, body feels 'lighter' & head feels clearer.
New Lab Test Results:
*** END EXAMPLE ***
The above is clear and organised and only has the essentials in it. This thyroid patient created a diary with time stamped (dated) entries with this type of information, which made it easy for her to track progress after any thyroid medication change (in this case it was T3 medication). Too much information, with many detailed descriptive comments, is almost as bad as too little, as it can be very difficult to understand it.
Summarising the vitals and symptoms collected into a few lines makes it easy to create a diary that the thyroid patient and their doctor or coach can easily assess. Pages of information with many detailed descriptive comments are much more difficult to use.
When the information is summarised tidily, and in a short amount of space, then any obvious patterns or results may be found far more easily. The type(s) of thyroid medication being used, and the doses and timings, need to be recorded along with the signs (heart rate, body temperature and blood pressure, and any other laboratory test results).
The time the thyroid patient gets up should also be recorded if they are using the Circadian T3 Method (CT3M). The get-up time is very important to have this if someone is using CT3M but helpful to know anyway. The time since any T4 meds were stopped is useful to record since it takes 8-12 weeks to fully clear excess T4, which in turn will lower reverse T3.
Put the T3 doses used with the times they were taken at the start and not mixed in with symptoms and signs.
The best times to take readings of signs like temperature, blood pressure and heart rate are:
1) When you have got up on a morning for the day.
2) During the first 30 minutes or so.
3) Just before a dose of T3 (or other thyroid medication) in the daytime (not the circadian dose).
4) Two to three hours after a daytime dose of T3 (or other thyroid medication).
5) An evening reading (which may be dealt with via the last point if the last T3 dose is late afternoon or early evening).
This timing of recording provides a 'before' and 'after' record of the effect of the doses of T3 This type of diary or record can be a godsend when trying to understand what is happening. Often, only by looking at this information before and after changes to medication can some trend or situation be fully understood. It may seem a lot of work, but it is very useful. You will need an oral thermometer and a home blood pressure meter to track vitals and symptoms.
ANY OTHER RELEVANT INFORMATION:
If there is anything else that you can think of that might be relevant then please explain this:
WHAT DO YOU HOPE TO ACHIEVE FROM THE COACHING SESSION:
Please explain what you most want from the session, as this will help me to focus my energies in the right direction: