THYROID SYMPTOM SURVEY

Patient Name:_____________________________________________________             Date:_____________________

 INSTRUCTIONS: Grade your symptoms according to the following:

I don’t have this.  Mild.   Moderate.  Severe.

                  0                1               2              3

HYPOTHYROID SYMPTOMS

1. More tired and sluggish than normal.                                         _________

2. Drier skin or hair than normal.                                                     _________

3. Sleep more than usual.                                                                _________

4. Weaker muscles.                                                                          _________

5. Colder than others.                                                                       _________

6. Muscles cramp more than usual.                                                _________

7. Poorer memory.                                                                            _________

8. More depressed.                                                                          _________

9. Slower thinking.                                                                             _________

10. Eyes are more puffy.                                                                  _________

11. Math is more difficult.                                                                 _________

12. Hoarser or deeper voice.                                                          _________

13. Constipated more often.                                                            _________

14. Coarser hair.                                                                               _________

15. Puffy hands and feet.                                                                  _________

16. Unsteady gait.                                                                             _________

17. Gain weight easily.                                                                     _________

18. Outer third of eyebrows thin.                                                      _________

The next 2 questions apply to Menstruating Females Only

19. Menses more irregular.                                                              _________

20. Heavier Menses.                                                                        _________

Total                                                                                                   _________

HYPERTHYROID SYMPTOMS

1. Tachycardia (fast pulse, heart racing).                                       _________

2. Palpitations (skipping of pulse or heart)                                    _________

3. Insomnia (can’t sleep).                                                                 _________

4. Shakiness (tremors).                                                                    _________

5. Increased sweating                                                                      _________

6. Brittle Nails.                                                                                   _________

7. Loss of appetite.                                                                           _________

Total                                        ____                                                      

    Prefire_______  Fire__________ F-PF___________   RMR______________