Self reported Grave’s disease DATA
NAME (THIS WON’T BE USED WHEN REPORT IS SHARED)
CODE # (WILL BE ASSIGNED TO YOU)
SEX/CURRENT AGE
LOCALE (COUNTRY OR IF USA GIVE ME STATE AND HOW TO ABBREVIATE IT)
ONSET AGE/YEAR (EXAMPLE 36/85)
SYMPTOMS WHILE HYPER; (LIST THEM…Rapid Pulse, Tremors, HyperBowels,Mood Swings, Depression Etc…)
WEIGHT WHILE HYPER ( Gain or Loss? EX: G 23 or L 35 )
TREATMENTS W/DATES.. ( RAI 87 OR PTU 18MO OR SUBTOTAL OR TOTAL THYROIDECTOMY)
RAI (YES OR NO) (THIS FIELD WILL BE USED TO SORT THE DATA EASILY)
EYE SYMPTOMS….YES OR NO & then DESCRIBE using WERNER CLASSIFICATION as below
CLASS I Elevation or retraction of upper eyelids, dryness and irritation
due to hyper state itself.
CLASS II Soft Tissue Involvement, swelling of eyelids.
CLASS III Proptosis, extophthalmos or bulging.
CLASS IV Double Vision Diplopia
CLASS V Exposed Cornea
CLASS VI Optic Nerve Damage
RE: eye Symptoms Date of occurance of each class….. PRETX POSTTX OR BOTH ??
EVER HYPO???? When?? HOW LONG ???
OTHER DISEASES?? OR notes?
POST TREATMENT SYMPTOMS……..LIST THEM…………
THANK YOU JEANNETTE
