Thyroid Assessment

Thyroid Function Assessment

Place an X by any symptoms that you are experiencing and place a check mark by any symptoms that you have experienced in the past:

Hypothyroid Symptoms:

____ Overall listless demeanor

____ Slow body movement and/or slow speech

____ Sluggish eye movements

____ Prominent bags under eyes

____ Difficulty swallowing on command

____ Cool skin, as well as low oral temperature

____ Skin that is excessively dry or rough

____ Dryness of scalp

____ Water retention or puffiness, especially in the face

____ Low blood pressure

____ Slow moving ankle reflexes

____ Loss of the outer one-third of eyebrows

____ Significant fatigue, lethargy, sluggishness, or history of low thyroid at an earlier age

____ Hoarseness for no particular reason

____ Chronic recurrent infection(s)

____ Decreased sweating even with mild exercise

____ Depression

____ Lack of motivation

____ Require excessive amounts of sleep to function properly

____ Slow to heat up, even in a sauna

____ Constipation despite adequate fiber and liquids in the diet

____ Brittle nails that crack or peel easily

____ High cholesterol despite good diet

____ Frequent headaches, especially migraine

____ Irregular menses, PMS, PCOS, endometriosis, fibroids

____ Unusually low sex drive

____ Red face with exercise

____ Accelerated worsening of eyesight or hearing

____ Palpitations or uncomfortably noticeable heartbeat

____ Difficulty in drawing a full breath

____ Mood swings, anxiety, panic, phobia

____ Gum problems

____ Mild choking sensation or difficulty swallowing

____ Excessive menopause symptoms, not well relieved with estrogen

____ Major weight gain

____ Aches and pains of limbs, unrelated to exertion

____ Skin problems of adult acne, eczema or severe dry skin

____ Vague and mildly annoying chest discomfort

____ Feeling off balance

____ Infertility

____ Annoying burning or tingling sensations that come and go

____ Problems with memory, focus, or concentration

____ More than normal amounts of hair coming out in the brush or shower

____ Difficulty maintaining stamina throughout the day

____ Mentally sluggish

____ Anemia

____ Dyslexia

____ Persistent visual changes

____ Prematurely gray hair

____ B12 anemia

____ Bipolar disorder

____ Raynaud’s syndrome

____ Mitral valve prolapsed

____ Carpal tunnel syndrome

____ Persistent tendonitis or bursitis

____ Atrial fibrillation

____ Alopecia

____ Calcium deficiency

____ ADD

____ Vitiligo

____ Neck inury

____ Low basal temperature

____ Slow pulse rate

____ Fibrocystic breasts

Hyperthyroid Symptoms:

____ Anxiety

____ Tremors

____ Excessive sweating

____ Racing heart

____ Arrythmia

____ Night sweats

____ Weight loss

____ Bulging eyes

____   Fast pulse

____   Easily excitable

____ Nervous and emotional

____  Bi-polar disorder

____ Excessive worry

____ Inward trembling

____ Difficulty gaining weight

____ Insomnia

____ Disturbed sleep

____ Restlessness

____ Irritability

____ Muscle weakness

____ Clubbing of fingers

Other Thyroid Indications:

Yes No

1. Have you been diagnosed with hypothyroidism? ___ ___

2. Have you been diagnosed with Grave’s Disease? ____ ____

3. Are you currently taking thyroid medication? ____ ____

4. Have you ever taken thyroid medication? ____ ____

5. Do you have a family history of thyroid issues? ____ ____

6. Do you have a family history of heart disease? ____ ____

7. Do you have a family history of autoimmune diseases? ____ ____

8. Do you have a family history of high cholesterol and/or

triglycerides? ____ ____

9. Do you have a family history of diabetes? ____ ____

10. Do you have a family history of celiac disease? ____ ____

11. Have you experienced a trauma? ____ ____

12. Do you have a personal history of ADD or other

learning disorders? ____ ____

13. Do you have a personal history of depression? ____ ____

14. Do you have a personal history of anxiety? ____ ____

15. Do you have a personal history of any mood disorders? ____ ____

16. Do you have a personal history of autoimmunity? ____ ____

17. Do you have a family history of mood disorders? ____ ____

18. Do you have a family history of alcoholism? ____ ____

19. Do you have a history of infertility? ____ ____

20. Have you ever had a miscarriage? ____ ____

21. Have you had a personal history of postpartum depression? ____ ____

22. Do you have problems controlling your blood sugar? ____ ____

23. Did you experience early menopause? ____ ____

24. Have you ever had reproductive issues such as a

hysterectomy, endometriosis, PCOS, or fibroids? ____ ____

25. Do you have a personal history of allergies and/or

asthma? ____ ____

26. Do you stay out of the sun and wear sunblock at all times? ____ ____