Thyroid
Thyroid Questionnaire
Thyroid imbalance may be related to many other secondary health concerns. Proper assessment and a treatment plan are important to optimize one’s health.
This subjective questionnaire will give your health care practitioner a quick summary of symptoms or signs that may be related to your thyroid gland. It is not a substitute for professional medical advice from your health care provider.
For each “Yes” answer, circle the Point Score in that section. Score the following with the numbers in brackets choosing the severity that best suits you when indicated.
Add your points at the end and enter in the total score.
1.____ Are you frequently cold, or have cold hands or feet?
2. ____ Do you have trouble “ getting going” in the morning?
3. ____ Do you feel sad or depressed , especially in the morning?
4. ____ Do you feel nervous or anxious?
5. ____ Do you experience constipation?
6. ____ Do you experience PMS?
7. ____ Are you unable to loose weight despite a good diet and exercise?
8. ____ Do you have hair loss from the arms, legs, head or lateral margins of the eyebrows?
If you have answered yes to more than 2 of the above symptoms you may have a thyroid condition.
It is recommended to consult with your health care professional team.
