Hashimoto’s Thyroiditis Registry and Treatment Recommendations
Date of completion: Year Month Day
Name: Gender: Marriage: Time of birth: Contact address (including zip code): Chen Xiaohong, Department of Otolaryngology, Head and Neck Surgery, Beijing Tongren Hospital
Cell phone number: E-mail address: MSN: QQ:
Thyroid disorders Diagnosis.
Other immune-related diseases
Hyperthyroidism Thyroid cancer Autoimmune diseases (vitiligo, oral ulcer, rheumatoid, others) Infertility Hashimoto’s encephalitis
Other diseases.
Thyroid function test Unit of examination.
Normal value
Examination time ( )
Examination time ( )
Examination time ( )
Check time ( )
Check time ( )
TT3 (or T3 or total triiodothyronine)
TT4 (or T4 or total tetraiodothyronine)
FT3 (free T3)
FT4 (free T4)
TSH (thyroid stimulating hormone)
Anti-Thyroglobulin antibody (Anti-TG)
Anti-Thyroid Peroxidase Antibody (Anti-TPO )
Anti-Triplex thyrogenic acid (RT3)
Thyroid ultrasound Unit of examination.
Whether the echo is homogeneous
Presence of nodules
Number of nodules
Maximum nodule size
Nodule border
Nodule shape
Blood flow
Description of calcification
Lymph nodes
Time of examination ( )
Time of examination ( )
Examination time ( )
Doctors who care about this disease: Department of Otolaryngology, Head and Neck Surgery, Beijing Tongren Hospital (1 Dongjiaominxiang Alley, Dongcheng District, Beijing 100730, China) Chen Xiaohong (Speciality: Head and Neck Oncology)
MSN: [email protected] E-mail: [email protected] QQ: 195 911 788 (thyroid disease care group) Personal Web Link.
Treatment advice for you (please send this spreadsheet to my mailbox, and I will return the treatment advice to your mailbox with this form).
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