Dr. Hubbard's Thyroid Dysfunction Assessment

Do you have any of these signs of low thyroid function?

Check the box if the question addresses a concern that applies to you.

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First Name Last Name

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Check box for "yes" *

Do you feel fatigued or exhausted more than normal? Do you gain weight for no clear reason or have difficulty losing weight on a low calorie diet and exercise program? Do you have cold hands and feet? Do you frequently feel cold when others do not? Does your body temperature run below the normal 98.2°? Do you find it hard to concentrate or remembering things? Do you feel depressed, restless, moody or sad? Is your hair rough, coarse dry, breaking, brittle or is falling out? Do you have thinning of your eyelashes or eyebrows, particularly the outer portion? Do your eyes feel gritty, dry, light-sensitive? Is your skin rough, coarse, dry, scaly, itchy, and thick? Do you have elevated cholesterol? Do you have puffiness and swelling around the eyes, eyelids, face, feet, hands and feet? Does your throat feel full, with pressure, or larger than usual? Do you have difficulty swallowing? Do you have pains, aches, stiffness, or tingling in joints, muscles, hands and/or feet? Do you experience tingling in hands or feet? Do you have carpal tunnel syndrome, tendonitis, or plantar fasciitis? Has your voice become hoarse and/or ‘gravelly’? Do you have a slow pulse? Do you have low blood pressure? Do you have reduced libido? Are you constipated (less than 1 bowel movement daily)? Women: Do you have irregular menstrual cycles (longer, or heavier, or more frequent) Women: Do you have a history of infertility or miscarriage?

Check box for "yes" for the following statements that apply to your family history and/or your personal 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 I grew up, live, or work near or at a nuclear plant

total score