Thyroid Assessment


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

Name
Email
Fatigue
Inability to exercise
Heavy feeling legs
Muscle pain
Muscle stiffness
Abnormal coldness
Abnormal or unexplainable weight gain
Elevated cholesterol
Decreased sweating
Irritability
Fluid retention
Infertility/repeat miscarriages
Heavy menstrual cycles, heavy clotting
Constipation
Afternoon fatigue
Slow pulse
Shortness of breath
Low sex drive
Tingling/numbness of extremities
Diarrhea
Shortness of breath
Poor memory/concentration
Brain fog
Shaky hands
Headaches
Agitation
Rapid pulse
Fine, brittle hair
Hair loss
Thinning skin
Thick-feeling tongue
Low blood pressure
Cracking, brittle nails
Pale, puffy face
Dry hair or skin
Iron anemia
Hoarseness
Swallowing pills or food is difficult
Swelling on front of neck
Poor sleep
Sleep is never restful
Needs more than 9 hours sleep
Depression
Heat Intolerance
Anxiety
Panic attacks
Loss of outer 1/3 of eyebrows
Muscle pain
AM basal temp under 97.6 degrees F
Family history of thyroid disorders