MP
Dr. Mit Panchani
Thyroid Module
Hypothyroid OPD
→ Fill
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Date
Age
Gender
Female
Male
Patient Name
Diagnosis
K/C/O Hypothyroid
Post-Op Hypothyroid
K/C/O Hyperthyroid
Newly Diagnosed Hypothyroid
Newly Diagnosed Hyperthyroid
MOA (months)
Compliance
Poor Compliance
Wt (kg)
HR (/min)
BP (mmHg)
Labs (TSH / FT3 / FT4)
Current Dose
Prescription Plan
New Dose (µg)
Drug (hyper only)
Duration
Follow-up
Clinical Note & Rx
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Name:
Age/Sex:
Date:
Weight
BP
Heart Rate
S. TSH
Advised Follow-up:
Dr. Mit Panchani
MBBS, MD General Medicine
Fellow in 2D Echo, PGCIH