St. Pete Health & Wellness



Hypothyroid Risk QuestionnaireName:Click here to enter text. DOB:Click here to enter text. Date:Click here to enter text. Email:Click here to enter text.This questionnaire assesses low thyroid function. For overactive thyroid see Hyperthyroid Risk Questionnaire. The more items checked below the greater the possibility you have thyroid dysfunction. Certain symptoms/associations have a higher likelihood than others.Please mark the box of any that apply. Indicate the severity of each symptom you are experiencing currently by typing a 1 – 5 (1=mild/5=severe) in the middle of the red line ( __ ). Some questions may not sound as if they are requesting severity information or you may be unsure of the severity. In these situations please enter your best guess. If the symptom is current, simply place a number in the provided space. If it is a symptom that you have had in the past, please indicate severity & type the word “past” in the space.When you have completed the form, save it and email it back to SPHW@ or call our office at 727-202-6807 to make an appointment.Risk Factors? I have a family history of thyroid disease? I have been treated for thyroid disease? I have had thyroid surgery? I have taken anti-thyroid medication? I have taken thyroid medication? I have been monitored for my thyroid? I’ve had temporary thyroiditis? I have/had a goiter / thyroid nodule? I have another autoimmune diseaseSymptoms/Associations__ I am gaining weight inappropriately__ I'm unable to lose weight__ I have poor circulation hands or feet__ I get cold hands and feet__ I feel cold much of the time__ I feel fatigued, exhausted__ Feeling run down, sluggish, lethargic__ I feel weak__ I have thinned and lost eyelashes__ I lost the outer portion of my eye brows__ My hair is coarse, dry, breaking, brittle__ I am losing my hair__ My skin is coarse, dry, scaly, and thick__ My nails are brittle__ My ears itch__ I have excess ear wax__ I have ringing in my ears__ I get dizzy__ My eyes feel dry or gritty__ I get blurry vision that clears with blinking__ My eyelids droop__ My eyes sometimes close on their own__ I have a hoarse or gravelly voice__ I have facial puffiness and swelling__ I have aches in joints, hands and feet__ I have carpal-tunnel syndrome__ I get injuries from repetitive exercise__ My hands or feet tingle / get numb__ I get muscle cramps__ I am stiff in the morning__ My memory is worse__ I have difficulty concentrating__ My thinking & speech have slowed__ My mood changes easily__ I feel depressed__ I have feelings of worthlessness__ I feel often sad__ I am losing interest__ I feel anxious / restless__ I feel agitated / irritable__ My reflexes are slow or absent__ I have restless legs__ I have trouble sleeping__ I wake to go to the bathroom__ I snore__ I get frequent headaches__ I get frequent infections__ Infections last too long__ I have asthma__ I have allergies__ I feel short of breath__ I yawn often__ I have odd feelings in my neck/throat__ I have chest tightness__ I have a history of heart disease__ I have high/low blood pressure__ I have blood pressure irregularities__ I have slow pulse / bradycardia__ I have palpitation__ I have high cholesterol / lipids__ I have diabetes / prediabetes__ I have decreased interest in sex__ I am less sexually aroused with sex__ It takes me a long time to orgasm__ I cannot achieve orgasm__ We can’t get pregnant__ I have / had tender breastsWomen__ I’ve had a miscarriage__ I’ve had a baby in the past 9 months__ I’ve had postpartum thyroiditis__ I do / have use/d birth control pills__ I have / had endometriosis__ I have / had cystic breasts / ovaries__ I have a family history of breast cancer__ I have / had breast cancer__ I have PMS__ I have severe menstrual cramps__ I am having irregular menstrual cycles (longer, heavier or more frequent)Men__ I have erectile dysfunction__ I have delayed or absent ejaculationThe more items checked the greater the possibility you have hypothyroidism. Certain symptoms/associations have a higher likelihood than others. Please return to SPHW@. If you have questions or wish to make an appointment, please call 727-202-6807. ................
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