Free Thyroid Questionnaire


Blog - Iodine DeficiencyThe below form has been designed to assess your thyroid function by asking you to rate a number of symptoms that are commonly associated with thyroid dysfunction.

Please tick the boxes below that best describe your symptoms, along with any comments you have about any of your answers. The form will add up your total score, and when you click “View My Results”, we will explain what your score means for your thyroid function.

Please note, this is a generic test which will give an overview of any potential issues with your thyroid function. We highly recommend that you follow up the test with a diagnostic test to get an accurate picture of how you thyroid is performing, so we can help you to get your body and hormones functioning at its optimum levels – so you can live well and feel great… naturally!

 

Name

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Do you suffer from any of the following symptoms? Please rate your symptoms below from a scale of 0-3 using the checkboxes below:

1. Feeling Tired and Sluggish

0 - None 1 - Mild 2 - Moderate 3 - Severe 

2. Dry Hair and Skin

0 - None 1 - Mild 2 - Moderate 3 - Severe 

3. Weak Muscles

0 - None 1 - Mild 2 - Moderate 3 - Severe 

4. Need for More Sleep

0 - None 1 - Mild 2 - Moderate 3 - Severe 

5. Muscle Cramps

0 - None 1 - Mild 2 - Moderate 3 - Severe 

6. Constantly Feeling Cold

0 - None 1 - Mild 2 - Moderate 3 - Severe 

7. Poor Memory

0 - None 1 - Mild 2 - Moderate 3 - Severe 

8. Depressed

0 - None 1 - Mild 2 - Moderate 3 - Severe 

9. Slow Thinking

0 - None 1 - Mild 2 - Moderate 3 - Severe 

10. Puffy Eyes

0 - None 1 - Mild 2 - Moderate 3 - Severe 

11. Difficulty with Maths

0 - None 1 - Mild 2 - Moderate 3 - Severe 

12. Deeper Voice

0 - None 1 - Mild 2 - Moderate 3 - Severe 

13. Muscle Joint Pain

0 - None 1 - Mild 2 - Moderate 3 - Severe 

14. Constipation

0 - None 1 - Mild 2 - Moderate 3 - Severe 

15. Coarse Hair or Hairloss

0 - None 1 - Mild 2 - Moderate 3 - Severe 

16. Low Sex Drive or Impotence

0 - None 1 - Mild 2 - Moderate 3 - Severe 

17. Puffy Hands and Feet

0 - None 1 - Mild 2 - Moderate 3 - Severe 

18. Unsteady Gait

0 - None 1 - Mild 2 - Moderate 3 - Severe 

19. Gain Weight Easily

0 - None 1 - Mild 2 - Moderate 3 - Severe 

20. Thinning of the Outer Eyebrow

0 - None 1 - Mild 2 - Moderate 3 - Severe 

21. Irregular Periods

0 - None 1 - Mild 2 - Moderate 3 - Severe 

22. Heavier Periods

0 - None 1 - Mild 2 - Moderate 3 - Severe 

23. Tachycardia (Rapid Heartbeat)

0 - None 1 - Mild 2 - Moderate 3 - Severe 

24. Palpitation (Skipping Heartbeat)

0 - None 1 - Mild 2 - Moderate 3 - Severe 

25. Insomnia

0 - None 1 - Mild 2 - Moderate 3 - Severe 

26. Shakiness

0 - None 1 - Mild 2 - Moderate 3 - Severe 

27. Increased Sweating

0 - None 1 - Mild 2 - Moderate 3 - Severe 

28. Brittle Nails

0 - None 1 - Mild 2 - Moderate 3 - Severe 

29. Loss of Appetite

0 - None 1 - Mild 2 - Moderate 3 - Severe 

YOUR TOTAL HYPO SCORE

YOUR TOTAL HYPER SCORE