Thyroid Assessment QuestionnairePersonal DataFirst Name *Middle NameLast Name *Email Address *PhoneThyroid InformationDo you currently have any of these symptoms?Palpitations (rapid or forceful heart beat)Poor concentrationMemory LossDifficulty sleepingExcessive need for sleepFatigueWeak musclesSore musclesAgitation/anxietyDepressionDry skinItchy skinUnusual hair lossDry hairCrackling nailsInfrequent bowel movements or hard stoolsFrequent bowel movements of loose stoolsUnexplained weight gainUnexplained weight lossPersistent pain or swelling at the front of the neckHoarsenessSensation of a lump in the throatEye pain or double visionSwelling or protrusion of the eyesChange in facial appearanceSweatingDifficulty tolerating coldHand tremorCheck all that apply to you.For Women Before Menopause OnlyLoss of menstrual periodsIrregular periodsExcessive menstrual flowCheck all that apply to you.Have you been pregnant or miscarried during the past 2 years?PregnantMiscarriedCheck all that apply to you.Do you have any family members with diagnosed thyroid disease? If yes, please indicate the diagnosis which applies to them, if known.Overactive thyroid glandUnderactive thyroid glandNodule or enlarged thyroid glandThyroid CancerUnknown thyroid diseaseOtherHave you ever been diagnosed with a thyroid disease? If yes, please indicate.Overactive thyroidUnderactive thyroidNodule or enlarged thyroid glandThyroid CancerOtherAre you currently being treated for a thyroid disease? If yes, please indicate.Thyroid hormone therapy (eg. Synthroid, Eltroxin, Cytomel)Antithyroid drug therapy (eg. PTU, Tapazole)OtherWere you ever treated for a thyroid disease in the past? If yes, please indicate all that apply.Thyroid hormone therapy (eg. Synthroid, Eltroxin, Cytomel)Thyroid surgeryRadioiodine therapy (not the diagnostic scan)Antithyroid drug therapy (eg. PTU, Tapazole)OtherDo you currently take any herbal remedies or dietary supplements specifically to benefit your thyroid? If yes, please list.Do you have any of the following medical problems?High Blood PressureHigh CholesterolHeart Disease or angina (chest pain)Do you have any of the following medical problems?CholestyramineAmiodaroneLithiumSend Message
