Hypothyroid Questionnaire

Hypothyroid Questionnaire*

Hypothyroid can have many symptoms as thyroid hormone is crucial to good health. Although western medicine relies primarily on blood TSH levels (thyroid stimulating hormone), many holistic doctors find this an incomplete and sometimes misleading test. For this reason we recommend testing blood or saliva levels of TSH, T3 and T4. Some doctors are also requesting to see reverse T3 as wells as Anti-Thyroid Antibodies. (The use of saliva for these tests is still considered investigatory.)

Along with the hormone tests we like to see several basal body temperature (BBT) readings(first morning underarm temperature) and a filled out thryoid questionnaire.

What to do if you suspect hypothyroid
  1. Fill out the thryoid questionnaire. The more yeses you have the more likely hypothyroid may be present.
  2. Take your basal body temperature (BBT) (first morning, under the arm). Anything below 97.7 is indicative of hypothyroid.
  3. Take a thryoid hormone test that incluldes THS, T3 and T4. Your can also incldue reverse T3 and anti-thyroid antibodies.
  4. Take an iodine loading test. Iodine is essential for thyroid health and is often deficient.
  5. Have a consultation with your doctor or doctor Forrest.

Once you submit your results Dr. forrest will take a look. If you wish further assistance you can contact our office for an office or phone consultation.

Hypothryoid Questions YES
1.

Do you have dry or scaly skin?

2.

Do you get fatigued easier then you used to?

3.

Do you have less than normal energy?

4.

Does cold temperature bother you more than others?

5.

Have you had an unexplained increase in weight recently?

6. Have you had an unexplained decrease in weight recently
7.

Has you hair become drier, more brittle or coarse?

8.

Have your nails become thin or brittle?

9.

Have you had a decrease in the amount of scalp or body hair?

10.

Do you have a decrease in eyebrows toward the side of your face?

11.

Is there a “dirty” or thickened skin appearance of your elbows or knees?

12.

Do you have pallor or paleness of your skin?

13.

Have you ever been told you are anemic?

14.

Have you been told you were B12 deficient or had pernicious anemia?

15.

Do you have a yellow color to your skin, palms, soles of feet or nails?

16.

Have you noticed a loss of skin pigmentation on your face or breasts?

17.

Do you have decreased sweating?

18.

Do you have any swelling of you face or throat (goiter)?

19.

Do your ankles swell?

20.

Have you ever had protruding eyeballs?

21.

Have you ever had pressure in the lower front of your neck or jaw?

22. Have any of your blood relatives ever had a thyroid condition?
23.

Do you have a problem with constipation?

24.

Do you suffer from generalized muscle and joint pain or cramping?

25.

Do you suffer from muscle cramps?

26.

Do you suffer from muscle weakness?

27.

Do you have headaches?

28.

Do you have mental confusion?

29.

Do you have delayed reflexes?

30.

Have sensed that your tongue is “thickened” or “swollen”?

31.

Do you have problems pronouncing words?

32.

Are you chronically depressed?

33.

Have you ever been told that you cholesterol is too high?

34.

Do you have a slow heart rate (<60)?

35.

Do you have a fast hear rate (>90)?

If your have taken your BBT, record results here.
Day 1 Day 2 Day 3 Day 4


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