Thyroid Assessment Welcome to the Thyroid Assessment! Please check off each statement that applies to you. Each is worth 1 point. Name Email Fatigue yes noInability to exercise yes noHeavy feeling legs yes noMuscle pain yes noMuscle stiffness yes noAbnormal coldness yes noAbnormal or unexplainable weight gain yes noElevated cholesterol yes noDecreased sweating yes noIrritability yes noFluid retention yes noInfertility/repeat miscarriages yes noHeavy menstrual cycles, heavy clotting yes noConstipation yes noAfternoon fatigue yes noSlow pulse yes noShortness of breath yes noLow sex drive yes noTingling/numbness of extremities yes noDiarrhea yes noShortness of breath yes noPoor memory/concentration yes noBrain fog yes noShaky hands yes noHeadaches yes noAgitation yes noRapid pulse yes noFine, brittle hair yes noHair loss yes noThinning skin yes noThick-feeling tongue yes noLow blood pressure yes noCracking, brittle nails yes noPale, puffy face yes noDry hair or skin yes noIron anemia yes noHoarseness yes noSwallowing pills or food is difficult yes noSwelling on front of neck yes noPoor sleep yes noSleep is never restful yes noNeeds more than 9 hours sleep yes noDepression yes noHeat Intolerance yes noAnxiety yes noPanic attacks yes noLoss of outer 1/3 of eyebrows yes noMuscle pain yes noAM basal temp under 97.6 degrees F yes noFamily history of thyroid disorders yes noTime is Up!
