Patient Intake — AxisThyroid

Personal Information

First Name *

Last Name *

Email *

Phone

Date of Birth *

Sex *

Are you a current resident of New York State? *

Yes No

We currently serve New York State residents via telehealth.

AxisThyroid is currently only available to New York State residents. We hope to expand to other states soon.

Current Symptoms

Select all that apply to you currently.

Other symptoms

Thyroid & Medical History

Have you been diagnosed with a thyroid condition?

Are you currently taking thyroid medication?

Yes No

Medication details

Current medications (non-thyroid)

Family history of thyroid disease?

Yes No Unsure

Thyroid history / additional context

Additional

How did you hear about AxisThyroid?

Additional notes