Thyroid Screening Questionnaire
The Institute for Functional Medicine
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
History
Rows
Yes
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
Rows
Yes
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 degrees 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 normal
I 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 feet
I 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 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)
Authorization to Receive Password Protected Attachment
*
I understand I will receive an email response at the provided email from FunctionalMedicine.MD upon submission of this document with a PDF of the completed agreement attachment. I must use the password "Patient#1" to open the PDF.
Submit
Should be Empty: