Hypothyroid Questionnaire

Do you have dry or scaly skin?

Do you get fatigued easier then you used to?

Do you have less than normal energy?

Does cold temperature bother you more than others?

Have you had an unexplained increase in weight recently?

Has you hair become drier, more brittle or coarse?

Have your nails become thin or brittle?

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

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

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

Do you have pallor or paleness of your skin?

Have you ever been told you are anemic?

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

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

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

Do you have decreased sweating?

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

Do your ankles swell?

Have you ever had protruding eyeballs?

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

Do you have a problem with constipation?

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

Do you suffer from muscle cramps?

Do you suffer from muscle weakness?

Do you have headaches?

Do you have mental confusion?

Do you have delayed reflexes?

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

Do you have problems pronouncing words?

Are you chronically depressed?

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

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

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