Specify if the patient has ever had any of the following conditions:
Diabetes? If yes, what type? - Select Yes or No.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button 
.
Optionally, select a year and/or description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Select one of the following descriptions:
Type 1.
Type 2.
Gestational.
Other - With this option selected, an Add description box is available. Optionally, enter up to 60 characters.
Thyroid problems of any kind? If yes, was it high or low thyroid? – Select Yes or No.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button .
Optionally, select a year and/or description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Select one of the following descriptions:
Hyperthyroidism (High).
Hypothyroidism (Low).
Goiter.
Thyroiditis.
Graves' disease.
Thyroid cancer.
Thyroid Storm (history of).
Other – With this option selected, an Add description box is available. Optionally, enter up to 60 characters.
Do you take a thyroid medication (e.g. Synthroid, levothyroxine)? – Select Yes or No.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button .
Optionally, select a year and/or description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Select one of the following descriptions:
Levothyroxine (Synthroid, Lexoxyl, Tirosint).
Methimazole.
Armour thyroid.
Cytomel.
Iodine.
Potassium Iodide (Thyro Shield).
Propylthiouracil.
Sodium Iodide (HiCon).
Tapazole.
Other – With this option selected, an Add description box is available. Optionally, enter up to 60 characters.