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Thyroid screening form

Start your journey to better health

Let us know you a little more. By providing us your health status, it helps our doctor to i give better lab result interpretation and advice.

Thyroid Screening Question

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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

I am gaining weight for no clear reason or am unable to lose weight with a diet and exercise program

My hands and feet are cold to the touch and I frequently feel cold when others do not

I feel fatigued or exhausted more than normal

I have been told I have high cholesterol

My hair is rough, coarse dry, breaking, brittle, or falling out

My skin is rough, coarse, dry, scaly, itchy, and thick

My nails have been dry and brittle, and break more easily

My eyebrows appear to be thinning, particularly the outer portion

My eyebrows appear to be thinning, particularly the outer portion

My voice has become hoarse and/or ‘gravelly’

I have pains, aches, stiffness, or tingling in joints, muscles, hands and/or feet

I am constipated (less than 1 bowel movement daily)

I feel depressed, restless, moody, sad

I have difficulty concentrating or remembering things

I have a low sex drive

My eyes feel gritty, dry, light-sensitive

My neck or throat feels full, with pressure, or larger than usual, and/or I have difficulty swallowing

I have puffiness and swelling around the eyes, eyelids, face, feet, hands and feet

Women: I am having irregular menstrual cycles (longer, or heavier, or more frequent)

Current Weight

Height

Your true gender?

Male

Female

We need this to process your tests — we respect that your identifying gender might be different.

How many hours of sleep do you have on average?

7-8

5-6

Less than 5

Are you a smoker?

Yes, I smoke at least a pack a day

Yes, I smoke around half a pack a day

I’m a social smoker

No

How often do you exercise every week?

I don't exercise much

< 120 minutes/week

120 - 150 minutes/week

>150 minutes/week

At least 5 minutes a day