The following questionnaire will give you an idea of
whether you should see your healthcare practitioner to get proper testing to
determine whether your thyroid is functioning at an optimal level.
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Yes
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No
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Risk Factors of Hypothyroidism
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Are you of female gender?
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Are you over 60?
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Do you have a family history of low thyroid?
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Have you had a miscarriage?
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Have you struggled with infertility?
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Have you recently been pregnant?
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Are your periods irregular or heavy?
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Have you ever had thyroid cancer?
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Have you ever been diagnosed with fibromyalgia?
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Have you ever been diagnosed with pituitary disease?
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Do you have a history of obesity?
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Do you have a family history of autoimmune disease?
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Have you ever had a biopsy for a thyroid lump or do
you have a lump?
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Have you ever smoked?
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Have you ever had x-rays of your neck or head?
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Yes
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No
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Signs & Symptoms
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Do you suffer from poor concentration?
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Do you sometimes feel weak?
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Do you feel lethargic?
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Do you have dry eyes?
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Do you have eczema, hives or acne?
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Are you suffering from lack of appetite?
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Do you ever feel depressed?
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Are you constipated?
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Are you struggling with weight gain?
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Do you suffer from brain fog?
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Are your wounds slow to heal?
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Is your sex drive low?
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Is your skin dry and do you perspire little?
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Do you ever feel like there is a lump in your throat?
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Do you often feel cold?
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Are your hands and feet cold?
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Do you have blurry vision?
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Is your hair dry?
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Have you suffered from hair loss?
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Do you suffer from fatigue?
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Do you have a slow heartbeat?
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Is your menstrual flow heavy?
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Are your eyelids swollen?
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Have you ever been diagnosed with fibromyalgia?
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Do your joints ache?
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Do you have high blood pressure?
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Do you have low blood pressure?
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Do you find the cold hard to bear?
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Do you have low blood sugar?
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Do you suffer from migraines or headaches?
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Do you have high cholesterol?
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Are you experiencing difficulty in losing weight?
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Is your heart function normal?
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Do you frequently have colds or the flu?
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Do you ever experience shortness of breath?
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Do you ever fell a fullness in your neck?
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Are your eyebrows thinning at the outer third?
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Do you ever feel dizzy?
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Are your legs ever swollen?
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Do you ever experience ringing in the ears?
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Is your voice hoarse?
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Do your muscles cramp up or are they achey?
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Are you suffering from memory loss?
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TOTAL
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f you scored ……… yes answers, …….. you should see
your healthcare practitioner or order a test.