Thyroid Assessment


Welcome to the Thyroid Assessment! Please check off each statement that applies to you. Each is worth 1 point.

Name
Email

Fatigue

1 out of 50

Inability to exercise

2 out of 50

Heavy feeling legs

3 out of 50

Muscle pain

4 out of 50

Muscle stiffness

5 out of 50

Abnormal coldness

6 out of 50

Abnormal or unexplainable weight gain

7 out of 50

Elevated cholesterol

8 out of 50

Decreased sweating

9 out of 50

Irritability

10 out of 50

Fluid retention

11 out of 50

Infertility/repeat miscarriages

12 out of 50

Heavy menstrual cycles, heavy clotting

13 out of 50

Constipation

14 out of 50

Afternoon fatigue

15 out of 50

Slow pulse

16 out of 50

Shortness of breath

17 out of 50

Low sex drive

18 out of 50

Tingling/numbness of extremities

19 out of 50

Diarrhea

20 out of 50

Shortness of breath

21 out of 50

Poor memory/concentration

22 out of 50

Brain fog

23 out of 50

Shaky hands

24 out of 50

Headaches

25 out of 50

Agitation

26 out of 50

Rapid pulse

27 out of 50

Fine, brittle hair

28 out of 50

Hair loss

29 out of 50

Thinning skin

30 out of 50

Thick-feeling tongue

31 out of 50

Low blood pressure

32 out of 50

Cracking, brittle nails

33 out of 50

Pale, puffy face

34 out of 50

Dry hair or skin

35 out of 50

Iron anemia

36 out of 50

Hoarseness

37 out of 50

Swallowing pills or food is difficult

38 out of 50

Swelling on front of neck

39 out of 50

Poor sleep

40 out of 50

Sleep is never restful

41 out of 50

Needs more than 9 hours sleep

42 out of 50

Depression

43 out of 50

Heat Intolerance

44 out of 50

Anxiety

45 out of 50

Panic attacks

46 out of 50

Loss of outer 1/3 of eyebrows

47 out of 50

Muscle pain

48 out of 50

AM basal temp under 97.6 degrees F

49 out of 50

Family history of thyroid disorders

50 out of 50