Thyroid Assessment Questionnaire

Personal Data

 
Wilmington, NC
Goldsboro, NC

Thyroid Information

 
Palpitations (rapid or forceful heart beat)
Poor concentration
Memory Loss
Difficulty sleeping
Excessive need for sleep
Fatigue
Weak muscles
Sore muscles
Agitation/anxiety
Depression
Dry Skin
Itchy Skin
Unusual hair loss
Dry hair
Crackling Nails
Infrequent bowel movements or hard stools
Frequent bowel movements of loose stools
Unexplained weight gain
Unexplained weight loss
Persistent pain or swelling at the front of the neck
Hoarseness
Sensation of a lump in the throat
Eye pain or double vision
Swelling or protrusion of the eyes
Change in facial appearance
Sweating
Difficulty tolerating cold
Hand tremor
 
Loss of menstrual periods
Irregular periods
Excessive menstrual flow
 
Pregnant
Miscarried
 
Overactive thyroid gland
Underactive thyroid gland
Nodule or enlarged thyroid gland
Thyroid Cancer
Unknown thyroid disease
Other
 
Overactive thyroid
Underactive thyroid
Nodule or enlarged thyroid gland
Thyroid Cancer
Other
 
Thyroid hormone therapy (eg. Synthroid, Eltroxin, Cytomel)
Antithyroid drug therapy (eg. PTU, Tapazole)
Other
 
Thyroid hormone therapy (eg. Synthroid, Eltroxin, Cytomel)
Thyroid surgery
Radioiodine therapy (not the diagnostic scan)
Antithyroid drug therapy (eg. PTU, Tapazole)
Other
 
High Blood Pressure
High Cholesterol
Heart Disease or angina (chest pain)
 
Cholestyramine
Amiodarone
Lithium
 

 

*Individual results may vary.