THYROID SYMPTOM QUIZ

Name *

First NameLast Name

Email (For Results)*

example@example.com

This questionnaire helps you determine the function of thyroid hormone in your body. It does not matter if you have had lab tests that say your thyroid is OK or that you may be taking prescription thyroid medication, you still may have problems with metabolism that directly relates to how thyroid hormone is functioning in your body.

SCORING: Select the score that most accurately describes your situation.

10 – If this is a noticeable issue or significant problem

5 – If this is a problem, but not a major issue

2 – If this happens every now and then, but you don’t notice it too much

0 – If you seldom or never have this issue.

Are you cold? Do your hands/feet feel cold a lot?*

10520

Are you overweight/obese? (10 if over 20 lbs, 5 if 10-19 lbs, 2 if 5-9 lbs)*

10520

Do you gain weight easily or struggle to lose weight?*

10520

Do you have abnormal cholesterol levels? (10 if over 250, 5 if 220-249, 2 if 201-219, or 10 if under 140, 5 if 141-160) Or elevated triglycerides? (10 if >350, 5 if 250-349, 2 if 150-249)*

10520

Do you struggle with depression in the winter/spring/fall?*

10520

Are you easily depressed, prone to depression, or feel less communicative or more withdrawn?*

10520

Does stress increase your irritability; keep you “on-edge” often?*

10520

WOMEN: Are your moods noticeably worse with/near your menstrual cycle or transition?*

MEN: Do you lack a morning erection? (never get one=10, sometimes=5, occasionally=2)*

Are you always tired? Do you awaken tired?*

10520

Do you need a lot of sleep and then still not feel rested?*

10520

If you sit/slow down in the daytime, do you tend to doze/nap or lose your energy when you stop?*

10520

Does your energy suddenly drop in the afternoon?*

10520

Do you rely on caffeine or other stimulants to stay awake during your day?*

10520

Is your hair falling out, thinning, or breaking? Have less body hair in general?*

10520

Are your eyebrows thinning on the outside portions?*

10520

Do you have dry/itchy skin? Do you have dry/brittle hair?*

10520

Are your elbows rough or scaly?*

10520

Are you prone to facial swelling, especially around the eyes, maybe more often in the morning?*

10520

Do you have frequent early morning headaches that generally improve over time?*

10520

Does your head feel heavy? Do you have “brain fog” or struggle with memory or concentrating?*

10520

Do you have a sore throat? Feel like your voice is hoarse or coarse?*

10520

Do you feel like your neck is swollen or feels full?*

10520

Do you have reflux/poor appetite/constipation? Strain to have a BM?*

10520

Do you get muscle cramps, charley horses, or general muscle weakness?*

10520

Do you have numbness in hands/feet or carpal tunnel syndrome?*

10520

TOTAL SCORE

Hit the "Submit" button to learn more about thyroid conditions and the treatment options available to you.

THYROID SYMPTOM QUESTIONNAIRE