New Patient Health Information Form
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- Bennett Townsend
- 5 years ago
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1 Dr. Gerard Rosney Dr. Joseph Rosney New Patient Health Information Form Date: Name: DOB: Age: Sex: M / F Home Phone # Cell # Work # Address: City: State: Zip: Marital Status: M / S / D / W Children: Y / N Ages: Who may we thank for referring you? Your hobbies: Do you exercise? Y / N How often? What type? Diet: Healthy / Ave / Poor Vitamins/supplements? Y / N Alcohol: Never/Rare/Moderate/Daily Have you consumed alcohol in the last 24 hours: Y / N When? Smoker: Y / N Packs per day: How Long: Past Smoker Y / N Date Quit: Occupation: Employer: Insurance Company: Policy #: Spouse s name: Spouse s DOB: Occupation: Employer: Insurance Company: Policy # Treatment and Finances: First and foremost the priority in this office is to provide the highest quality of care to all patients. As a courtesy our office will provide each patient with a detailed invoice that can be submitted to insurance for reimbursement directly from your insurance company to you. Please be sure to let us know if you would like an invoice. Though we are happy to provide you with this, it is our policy to collect payment in the office at the time of service. I understand that payment is due at time of service and as a courtesy this office will provide me with a detailed invoice that may be submitted to my insurance company. I have questions about this policy or have other financial related concerns and would like to speak to someone in the office about this.
2 As a society we are ranked 50th in the world when it comes to health, but at TLC Chiropractic Wellness Center we take pride in helping people to reach their optimum health and wellness. In order to help you best, we would like an honest assessment of where you believe your current level of health is. So please place an X on the scale below marking where you believe your level of health and wellness is at this time. Then place a circle O on the diagram indicating where you would like your health and wellness to be. Very Poor Challenged Less Than Ideal Generally Good Ideal Health Patient Health Profile What brings you into our office? Please briefly describe your chief concern, including the impact it has had on your life. If you have no symptoms or concerns and are here for Chiropractic Wellness Services, please skip to the General History page. Primary Health Concern: When did your health challenge start? Is it getting worse? Yes / No How often are you in pain? _ Is it constant? Yes / No Rate the severity of your pain on a scale from 1 (least) to 10 (severe): Current Today Worst Ever Average Type of pain: (circle all that apply) Sharp / Dull / Throbbing / Numbness / Aching / Shooting / Burning / Tingling Cramps / Stiffness / Swelling / Other: Does it interfere with Work / Sleep / Daily Routine / Recreation Activities that make problems worse: Sitting / Standing / Walking / Bending / Lying Down / Activities that make problems better: Have you received any other type of treatment for this health concern? Y / N If Yes, was the cause of your health concern identified? Y / N If Yes, what was the recommended course of care? Have you had previous chiropractic wellness care? Y / N Details: Please mark your areas of pain on the diagram on the left. Worst Pain Possible Please mark a X at the level of your pain on the scale to the right. No Pain
3 General History Given that all prescription medications have side effects, some very serious, please tell us what prescription or over the counter medications you are currently taking and why. Supplements are becoming more popular these days as people are looking for more natural ways to manage their own health and wellbeing. Please tell us what supplements you are taking and why. List any traumatic injuries or car accidents: List any doctors you are currently seeing List all surgeries/hospitalizations and dates: Do you have any of the symptoms below today? Sunburn Swelling Headache Cold / Flu Open Cuts, Bruises, Burns Irritated Skin Rash Poison Ivy Slips and falls, although common have a direct impact on your health and wellbeing. Even MINOR falls or accidents can cause long term stress, strain and damage to the spine. In addition to the traumatic injuries listed above, please list any additional slips, falls, etc that you can recall, even if minor. The doctor of the future will give no medication, but will interest his patients in the care of the human frame, diet and in the cause and prevention of disease. Thomas Edison Life is not merely to be alive, but to be well. Marcus Valerius Martial
4 Health Concerns Checklist Please indicate on the list below, C for current or P for past. Because the Nervous system controls everything in your body, it is common that current health challenges can be related to the problems you are seeking care for in our office. Please indicate if you currently have or have had any of the following symptoms or health conditions. AIDS/HIV Dizziness Loss Alcoholism Allergies Emphysema Anemia Epilepsy Anorexia Fainting Appendicitis Fatigue Arthritis Asthma Fractures Glaucoma Back Pain Goiter Bleeding Disorders Headaches Breast Lump Bronchitis Heartburn Bulimia Heart Disease Cancer Hepatitis Hernia Chemical Dependence Herniated Disk High Constipation Cold Hands Cold Feet Cold Sweats Chicken Pox Depression/Anxiety Blood Pressure High Cholesterol Hot Flashes Irritability Kidney Disease Lights of Smell Loss of Taste Measles Menstrual Pain Menstrual Irregularity Miscarriage Sclerosis Mononucleosis Multiple Mumps Neck Stiffness/Pain Nervousness Numbness in Arms Numbness in Fingers Numbness in Hands Numbness in Legs Numbness in Toes Osteoporosis Pacemaker Parkinson s Pinched Nerve Pneumonia Problem Prosthesis Psychiatric Care Rheumatoid Arthritis Rheumatic Ringing in the ears Scarlet Sleeping Problems STD Attempt Stroke Suicide Tension Thyroid Problems Tonsillitis Tuberculosis Tumors/Cysts Typhoid Ulcer Upset Stomach Urinary Tract Inf. Vaginal Infection Whooping Cough Diabetes Bother Eyes Liver Disease Diarrhea Polio Loss of Balance Prostate If you have any additional health concerns not listed above, please indicate below: FAMILY Health History Please mark below any conditions that apply to your FAMILY health history. High Blood Pressure Heart Disease Emphysema Diabetes Kidney Asthma Seizures HIV Positive Disease Headaches Circulation Back Problems Cancer Ulcer / Stomach Problems Osteoporosis Illness Arthritis Mental Problems
5 Lifestyle Questions It has been shown that daily lifestyle stress significantly impacts your overall health and wellbeing. As a family wellness office we specialize in not only addressing the cause of your health challenges, but we also focus on teaching you how to manage the lifestyle stresses that are keeping you from reaching your optimum health and wellness. Please rate the following and circle ALL answers that apply to your habits: (1 being very poor and 10 being excellent) Eating Habits A. I eat 35x s a day B. I eat fruits and vegetables daily C. I eat out 23 times weekly (min) D. I drink 35 sodas weekly E. I crave sweets F. I don t watch what I eat Sleep A. I sleep 79 Hours a night B. I wake up well rested C. I wake up tired D. I toss and turn E. I stay up late Exercise Habits A. I exercise 35 times a week B. I walk daily C. I don t exercise D. I want to exercise E. I sit (at a computer) 68 hours a day Mind Set A. I have a positive outlook B. I am generally in a good mood C. I share my feeling easily D. I have a negative outlook E. I am generally in a bad mood F. I bottle things up inside General Health A. I am not on medication B. I take care of myself C. I watch what I eat D. I base my health on what everyone around me is doing E. I think I am healthy but know I could make some changes to be even healthier On a scale of 010 please describe your levels of stress in the following categories of health: (0= none / 10=extreme) Occupational Social Emotional Spiritual Physical Mental Environmental You re Almost There Thank you for providing us with the information that can help us to better serve you and help you to be in the best health you can be!
6 Health Goals At our office we pride ourselves in helping you to achieve phenomenal results with your health and wellness. In order for us to truly help you to be as healthy as possibly, it is important that we understand your goals for your overall health and wellbeing. Please list your goals for your health and wellness in the spaces provided. Physical Goals Nutrition Goal Stress / Emotional Goals How can we help you? It is our goal with every patient that they might live a LONGER, HAPPIER, and HEALTHIER life in some way as a result of the care, education, and inspiration they receive in this office. Though this is our desire, we want to know how you feel. Please answer the following questions. If we find that there is a need for you to make dietary changes, would you like our recommendations? Yes No If we find that there is a need for you to begin general or specific exercises would you like our recommendations? Yes No If we find there is a need to address emotional or physical stress in your life, would you like our recommendations? Yes No On a scale of 110, with 10 being the highest, how much do you want to get rid of your health problems and move toward wellness, so that you can function better and feel great? Assuming that we could help you with your conditions or health concerns, is there anything that would prevent you from following through with a treatment plan? Yes No At TLC Chiropractic we are always here to answer any questions you have about your health or your care at our office. If you have any questions or concerns now, please specify below. Thank you for taking the time to complete all the information necessary to assess you health concerns and goals so we can begin to help you along the path to wellness! I consent to a complete chiropractic examination and any other diagnostic testing that the doctor deems necessary. I understand the doctor will do their best to explain as much as possible about procedures pertaining to testing and care, and that if I have questions at any time I will ask. Signature Date
NPM INTAKE FORM: ADULT INFORMATION: Name: Age: Date:
NPM INTAKE FORM: ADULT INFORMATION: Name: Age: Date: Address: City/State/Zip: Home Phone No.: Work Phone No: Cell Phone: Email Address: Gender: Date of Birth: Occupation: Best Time to Contact: Number of
NPM INTAKE FORM. INFORMATION: Name: Age: Date: Home Phone No.: Work Phone No: Cell Phone: Address:: Gender: Date of Birth:
NPM INTAKE FORM INFORMATION: Name: Age: Date: Address: City/State/Zip: Home Phone No.: Work Phone No: Cell Phone: Email Address:: Gender: Date of Birth: Occupation: Best Time to Contact: Number of Children
NPM INTAKE FORM INFORMATION: Name: Age: Date:
NPM INTAKE FORM INFORMATION: Name: Age: Date: Address: City/State/Zip: Home Phone No.: Work Phone No: Cell Phone: Email Address:: Gender: Date of Birth: Occupation: Best Time to Contact: Number of Children
PATIENT REGISTRATION
PATIENT REGISTRATION Last Name First Name MI Street Address City State Zip Code Social Security # - - Email Address Home Phone( ) Cell Phone( ) Sex Male Female of Birth Age Marital Status Married Single
Last First MI. Full Mailing Address:
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Chiropractic Registration and History
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Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address
Today s Date Contact Information Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address Phone numbers and E-mail (please check numbers to call or leave a message) Home
Registration and History Form
Registration and History Form PATIENT INFORMATION Date: / / Patient Address City State Zip Sex M F Age Birthdate Occupation _ Employer Spouse s Name _ Sex M F Age Birthdate Occupation Spouse s Employer
NPM INTAKE FORM. Home Phone No.: Work Phone No.: Cell Phone:
NPM INTAKE FORM INFORMATION: Name: Chosen Name (What would you like to be called?): Address: Date: Age: City/State/Zip: Home Phone No.: Work Phone No.: Cell Phone: Email Address: Date of Birth: Occupation:
Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic th Avenue Surrey BC V4A 2H9 Tel: Fax:
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Patient Information. Name: Last First MI. Address: Street City State Zip
Date: WELCOME TO: Name: Address: Patient Information Last First MI Street City State Zip Phone # : (Mobile) (Home) (Work) Can we leave a voicemail or text message? Yes No Email: Date of Birth: Gender:
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Date of Birth: Age: Sex: Male Female Marital. Driver's Lic S M D. Status: Address:
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Personal &Work Information Date: Patient Name: Age: City: State: Zip: Primary Care Physician: PCP Phone:
Personal &Work Information Date: Patient Name: Age: Birth Date: / / Preferred Name: Gender: Home Phone: Address: Mobile Phone: City: State: Zip: Occupation: Employer: Work Phone: Email: Emergency Contact:
(City) (State) (Zip) Number of Children and ages. Policy Holder Name: D.O.B. :
Patient Information : MP Name: Last First MI Email address: Mailing Address: (City) (State) (Zip) Phone # (H) (W) (Other) Can we call you at work? Yes No of Birth: Sex: Male Female SS#: Marital Status:
Chiropractic Case History/Patient Information
Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital:
PATIENT NAME DATE CONSULTATION QUESTIONNAIRE
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Health Questionnaire
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WELCOME to the Florence Chiropractic and Wellness Center.
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CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
(City) (State) (Zip) Phone # (H) (W) (Other) Employer Address: Emergency contact: Name: Relation: Phone #: Policy Holder Name: D.O.B.
Patient Information : Name: Last First MI Email address: Mailing Address: (City) (State) (Zip) Phone # (H) (W) (Other) Can we call you at work? Yes No of Birth: Sex: Male Female SS#: Marital Status: Single
PATIENT INFORMATION Please print clearly and complete all blanks
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PATIENT INFORMATION. Name Last First Middle. Address Number Street Name Apt# Home Phone Work Phone Cell Phone. Date of Birth / / Age Sex: Male Female
Today s Date PATIENT INFORMATION Name Last First Middle Address Number Street Name Apt# City State Zip Home Phone Work Phone Cell Phone Date of Birth / / Age Sex: Male Female Employed Full-Time Student
(City) (State) (Zip) Number of Children and ages. Policy Holder Name: D.O.B. :
Patient Information Date: MP Name: Last First MI Email address: Mailing Address: (City) (State) (Zip) Phone # (H) (W) (Other) Can we call you at work? es No Date of Birth: Sex: Male Female SS#: Marital
Primary Health Concerns Please use the following to best describe the primary reason you are seeking medical care today.
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PATIENT HISTORY 1 Date of Birth Age Social Security # Last First Middle Initial Address City ST Zip Phone (H) (W) (C) Email May we send you our online newsletter? Yes No Your Occupation Employer Spouse
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: Patient Information Name: Email address: Last First MI Mailing Address: City State Zip Phone # (H) (W) (Other) Can we call you at work? q Yes q No of Birth: Sex: q Male q Female SS#: Marital Status:
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: VRC Name: Last First MI Email address: Mailing Address: (City) (State) (Zip) Phone # (H) (W) (Other) Can we call you at work? Yes No of Birth: Sex: Male Female SS#: Marital Status: Single Married Divorced
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PERSONAL INFORMATION REASONS FOR SEEKING CHIROPRACTIC CARE
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Address Street Address City State Zip Code. Address Street Address City State Zip Code
Male Initial Visit Intake Form PATIENT INFORMATION Today s Date Last Name Mid Initial First Name Date of Birth Address Home Phone Social Security Number Street Address City State Zip Code Cell Phone E-mail
Liver Health: Do you have liver problems? Yes No If so, please specify:
Medical History General Last Name: First Name: Date of Birth: Age: Contact Number: Are you in good health to the best of your knowledge Medical Information: Please list any physicians you see and their
Date: Name: Date of Birth: Age: Mailing Address: City State Zip. Spouse s Name: Spouse s Employer: Spouse s Occupation:
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Date: Patient Name: Age : Date of Birth: Gender: Female Male Marital Status: #Children: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: E-mail: Person to Contact in Case of Emergency: Relationship
My Certification I certify that the above information is correct and I request services. X Signature of patient or person acting on patient's behalf
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How frequent are the symptoms present? (#2) Constant (76-100%) Occasional (26-50%)
Name Date Occupation Age Birthdate Sex: M F Previous Chiropractor, if any: Present Concern(s): What bothers you most? (concern #1) Next most? (concern #2) Other Concerns: When did the problem first begin?
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Mailing Address: City: State: Zip Code: How did you hear about our practice? (Check one) Internet? Which search engine did you use?
: Patient Information Name: Last First MI Email address: Mailing Address: City: State: Zip Code: Phone # (H) (W) (C) of Birth: Age: Sex: Male Female SS#: Marital Status: Single Married Divorced Widowed
Employed? Yes No Employer Name. Occupation. Problem Onset Frequency Severity E.g. Headaches June times per week Mild / Moderate / Severe
PLEASE NOTE: This file must be saved to your desktop before and after completing! PATIENT INFORMATION Date First Name SSN Sex Marital Status Middle Name Birth Date Last Name Height Spouse Name Address
Patient Intake Form Gray Chiropractic Health Clinic LLC 360 East International Airport Road, Suite #4 Anchorage, Alaska (907)
Patient Intake Form Gray Chiropractic Health Clinic LLC 360 East International Airport Road, Suite #4 Anchorage, Alaska 99518 (907)563-7700 PATIENT DEMOGRAPHICS Today's Date: *** PLEASE WRITE IN BLACK
INFORMATION/APPLICATION FOR CARE
INFORMATION/APPLICATION FOR CARE The following information is needed in order to better serve you. Please complete all questions. If you need help please ask. Name Home Phone Work Phone Cell Phone E-Mail
Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS
CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:
Hamilton Back Clinic
Hamilton Back Clinic Intake Form Name: City: Address: Postal Code: Phone: Sex: M F Date of Birth: Month/Day/Year E mail: Emergency Contact: Name/Phone: Name of Family Physician (MD): Employer: Employer
Don Wheeler LMT. Joleen Kolk LMT Neuromuscular Therapy Corrective Massage Therapy
Don Wheeler LMT. Joleen Kolk LMT Neuromuscular Therapy Corrective Massage Therapy Patient Number: Date of First Visit: Last Name: First Name: MI: Address: City: State: Zip Code: Email address: Phone: H
Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy
Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy Terms of Acceptance When a patient seeks health care in our office and we accept a patient for such care, it is essential the patient
Adult Health History Summary
Adult Health History Summary Name Age Date of Birth Address City Province Postal Code Phone (home) (cell) Occupation Email May we contact you via email? YES NO Emergency Contact Phone # How did you hear
Inner Balance Acupuncture
Patient Information Inner Balance Acupuncture 274 Southland Drive, Suite 101, Lexington, KY 40503 859-595-2164 www.acupunctureky.com Name: Today s date: Age: Male Female Marital status: Date of Birth:
PATIENT INTRODUCTION
PATIENT INTRODUCTION Personal History: Mr. Mrs. Miss Ms. Dr. Name: First Middle Last Your Address: _ City: Prov: Postal Code: Telephone: Home: Bus: Cell: E-Mail: Check this box if we may contact you via
Name: (Last) (First) Name you prefer to be called: Patient Address for shipping: (No PO Boxes)
AMI: Intake /Chiro 1 Patient Information Form Name: (Last) (First) (MI) Name you prefer to be called: Patient Address for shipping: (No PO Boxes) City: State: Zip: Phone: Cell: E-mail: Birthdate: SS #:
Date: Cell phone Carrier: VZW: AT&T: Tmobile: Other: Phone #(C) (W) (Other)
WELCOME Patient Information : Name: Email address: Last First MI Cell phone Carrier: VZW: AT&T: Tmobile: Other: Mailing Address: Phone #(C) (W) (Other) Can we call you at work? Yes No of Birth: Sex: Male
Patient # (assigned by office) Full Name: Social Security # Address: City: State: Zip: address: Home Phone Cell Phone:
We appreciate the opportunity to help you get back to the health. The more accurate and complete the information you give us, the better service we can give you. Date: Patient # (assigned by office) Full
Welcome To Health and Wellness Alternatives!
Welcome To Health and Wellness Alternatives! The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in diet, and in the cause and prevention of disease.
Address City State Zip. Home Phone Cell Work. (For SHPT use only) Emergency Contact Phone
Somerset Hills Physical Therapy, PC 180 Mount Airy Road, Suite 103 Basking Ridge, NJ 07920 Phone (908) 766-1407 Fax (908) 953-8454 wwwsomersethillsptcom Patient Information: Name Sex M F Date of Birth
Personal and Family Health History
Personal and Family Health History Date Name Social Security Address Occupation City State Zip Employer Phone: (H): (W): Marital Status: S M D W E-mail Spouse s Name Date of Birth Age Spouse s Occupation
NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny. Section 1: Today s Date: Date of Birth: Age:
Baylor Physical Medicine and Rehabilitation NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny Dear Patient: Please complete this questionnaire before you come for your appointment. Be sure to call us as soon
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
![Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?](/thumbs/87/97078208.jpg "Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?")
ENDOCRINOLOGY HEALTH HISTORY What is the reason for your visit? MEDICATIONS List current prescription and over-the-counter medications. Also list current vitamin, herbal, and nutritional supplements: MEDICATION/SUPPLEMENT
Patient Re-Examination Form
Harrisburg Family Chiropractic 220 S. Cliff Ave. Ste 106 Harrisburg SD 57032 (605) 767-7463 Name: Date: / / Patient Re-Examination Form Please fill out the information that has changed since your last
Patient Intake Form. Name: Street Address: Apt #: City: State: Zip Code: Phone Numbers: Home: Cell: Other: SS#: Birth Date: Age: Gender (circle) M
Terry Wulster, D.C. Andy Smith, D.C. Chiropractic & Wellness Care 35 W. Main Street, Suite 100 Denville, NJ 07834 Office: 973.625.2600 Fax: 973.625.2650 Chiropractic healthcare and wellness are possible
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart