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Walter Reed National Military Medical Center

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Walter Reed National Military Medical Center > Apps > Endocrinology > Endocrinology
 

Endocrinology Questions

 


Patient Name *

Sponsors last 4 *

Date of birth (mm/dd/yyyy format) *

Military Status *
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Marital Status *
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Race *
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Date of Endocrinology/Diabetes appointment (mm/dd/yyyy format) *

Referring or Primary Care Provider Name

Referring or Primary Care Provider Location

Are you retired? *

If not, Occupation/current job

Military Pharmacy Location

1. Main reason for Endocrinology Consultation (e.g. thyroid, diabetes, osteoporosis, etc.) *

2. List your symptoms (e.g. feeling more tired, weight changes, reported lab or Xray abnormality) *

3. How long has each symptom been present (e.g. 2 weeks, 2 months) *

4. How severe are the symptoms? Please list each symptom and grade it on a scale from 1 (very mild) to 10 (very severe) *

5. What makes each of these symptoms better or worse *

Medication Allergy: Are you allergic to any medications? *

If yes, please list

Past Medical History: Please list all medical conditions that your doctors have diagnosed *

Past Surgical History: Have you had any major surgeries in the past? Please provide approximate date

List all medications that you are currently taking (write name, dose, and schedule, including over-the-counter, supplement, and herbal medications) *

Have you had an X-ray, CT scan, MRI, blood tests, or other studies that are related to your problem or visit? Please bring a copy of the report and, if possible, the actual films (or disk) to the appointment

Family History: Please tell us about the medical conditions of your family (check all that apply)
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If others, please describe

Social History

Do you drink alcohol *

If so, how much and how frequently

Do you smoke tobacco *

If so, how much and how frequently

Have you recently had or do you currently have (check all that apply)
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Contact

Location
Building 19 Floor 5

Hours of Operation
8:00 – 16:00 Mon - Fri

Contact Us:
(301) 295-5165
(301) 295-5170 (fax)

Online Questionnaire

Patient Appointment Call Center
855-CAP-MED1 (227-6331)

Referral Required
A consult (referral) from your TRICARE Primary Care Provider is needed in order to make an appointment with us.

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