Request edit access
THYROID SYMPTOM SURVEY - DrTriFixx & Nitek Medical                                                                                                                                                                                                                                          
Please answer the following symptom questions based on how you have been feeling over the past three (3) months, so that our medical team can better understand your current state of health.

To help us gain a better insight into your overall profile, please take the time to note your medications by name and dosage, when prompted.

Warm regards,

The DrTriFixx & Nitek Medical Team
Sign in to Google to save your progress. Learn more
Patient Name *
Sex *
Date Of Birth *
MM
/
DD
/
YYYY
Height (please state in inches or centimetres) *
Weight (please state in pounds or kilograms) *
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report