Thyroid Cancer Screening Recommendation Form
Use this form to assess key risk factors and symptoms to determine if thyroid cancer screening is recommended.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Female
Male
Other
Do you have a family history of thyroid cancer?
*
Yes
No
Not sure
Have you ever been diagnosed with a thyroid disorder?
*
Yes
No
Have you ever received radiation treatment to the head, neck, or chest?
*
Yes
No
Do you currently have a lump or swelling in your neck?
*
Yes
No
Have you experienced any of the following symptoms? (Select all that apply)
*
Hoarseness
Difficulty swallowing
Persistent cough
Neck pain
None of the above
Have you ever had abnormal thyroid blood test results?
*
Yes
No
Not sure
Clinician Notes or Recommendation
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