Thyroid screening form

Thyroid Check

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Full Name*

Phone

Email*

History & Health Status

Put a check by the following statements that apply to your family history, your personal history, and the symptoms that you may have

History

My family (parent, sibling, child) has a history of thyroid disease

I've had a thyroid problem in the past

A member of my family or I have currently or in the past been diagnosed with an autoimmune disease

Women: I have a history of infertility or miscarriage

I have been told I have high cholesterol

history of high blood pressure

I have been told I have high blood sugar

I have carpal tunnel syndrome, tendonitis, or plantar fasciitis (present or in the past)

Do you have any of below signs and symptoms