Hypothyroidism Questionnaire

Please carefully consider the symptoms listed below, and check only the those you experience regularly.

SYMPTOMS Yes
1. Are your skin and finger nails thick?
2. Do you have dry skin?
3. Do you have a hoarse voice?
4. Do you have thinning hair, hair loss, or coarse hair?
5. Are you cold when every one else is warm?
6. Do you have colds hands and feet?
7. Is your basal body temperature is less than 97.8 first thing in the morning (under arm basal body thermometers are avail able at most drug stores)?
8. Do you have muscle fatigue, pain, or weakness?
9. Do you have heavy menstrual bleeding, worsening of premenstrual syndrome, other menstrual problems, and/or infertility?
10. Have you experienced a loss of sex drive (decreased libido)?
11. Do you have severe menopausal symptoms (such as hot flashes and mood swings)?
12.Have you experienced fluid retention (swelling of hands and feet)?
13. Do you experience fatigue?
14. Do you have low blood pressure and heart rate?
15. Do you have elevated cholesterol?
16.Do you have trouble with memory and concentration or “brain fog”?
17. Do you wake up tired and have trouble get ting out of bed in the morning?
18. Do you have a loss of or thinning of the outer third of your eye brows?
19. Do you have trouble losing weight, or have you experienced recent weight gain?
20. Do you experience depression and apathy or anxiety?
21. Do you experience constipation?
22. Have you been diagnosed with autoimmune dis ease (e.g., celiac disease, rheumatoid arthritis, multiple sclerosis, lupus) allergies, or yeast over growth (all of which can affect thyroid function)?
23. Are you or have you been exposed to radiation treatments?
24. Are you or have you been exposed to environmental toxins?
25. Do you have a family history of thyroid problems?
26. Do you drink chlorinated or fluoridated water?