Thyroid Questionnaire

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HISTORY

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

  • I’ve had a thyroid problem (i.e., hyperthyroidism, Graves’ disease, Hashimoto’s thyroiditis, post-partum thyroiditis, goiter, nodules, thyroid cancer) in the past

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

  • I have had radiation treatment to my head, neck, chest, tonsil area, etc.I

  • grew up, live, or work near or at a nuclear plant

  • Women: I have a history of infertility or miscarriage

SIGNS & SYMPTOMS

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

  • My “normal” body temperature is low (below 98.2 when I take it)

  • 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 normalI have a slow pulse, and/or low blood pressure

  • 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 voice has become hoarse and/or “gravelly”

  • I have pains, aches, stiffness, or tingling in joints, muscles, hands and/or feetI have carpal tunnel syndrome, tendonitis, or plantar fasciitis

  • 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 driveMy 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)

ASSESSMENT

Please review your responses. If you checked two or more questions above you may have a thyroid condition that requires a comprehensive assessment.