Thyroid Assessment/Intake Form Thyroid Assessment / Intake Form "*" indicates required fields Step 1 of 10 10% FacebookThis field is for validation purposes and should be left unchanged.Patient Name*Date of Birth* MM slash DD slash YYYY Age*Gender*Occupation*Email* Chief Complaint & Motivation For VisitWhat prompted you to seek evaluation for thyroid issues today? Please describe your primary concerns and how long you've been experiencing them:*What specific symptoms or changes made you think this might be thyroid-related?*Have you been told by another healthcare provider that your thyroid is "normal" but you still don't feel well?* No Yes If yes, please explain* Current Symptoms Assessment Rate each symptom: 0 (none) to 5 (severe)Energy & MetabolismFatigue/low energy*012345Weight gain (unexplained)*012345Difficulty losing weight*012345Feeling cold/cold intolerance*012345Cold hand and feet*012345Slow metabolism*012345Mood & CognitiveDepression/low mood*012345Anxiety*012345Brain fog/mental sluggishness*012345Memory problems*012345Difficulty concentrating*012345Irritability*012345 Physical SymptomsHair loss/thinning*012345Dry skin*012345Brittle nails*012345Constipation*012345Muscle weakness*012345Joint pain*012345Swelling (face, hands, feet)*012345Hoarse voice*012345Sleep & HormonalInsomnia/sleep disturbances*012345menstrual irregularities*012345Decreased libido*012345Infertility concerns*012345When did these symptoms first begin?*Have symptoms been* Gradual onset Sudden onset Worsening Stable Thyroid HistoryPrevious thyroid testing* Never tested Tested within last 6 months Tested over 6 months ago Results* Normal Abnormal Don’t Know If previously tested, what was checked? TSH only TSH + T4 Full thyroid panel Unknown Family history of thyroid disease Hypothyroid Hyperthyroid Goiter Thyroid cancer Hashimoto's Graves' disease Unknown Personal history Thyroid nodules Goiter Previous thyroid surgery Radioactive iodine treatment Currently taking thyroid medication Triggers & Lifestyle FactorsRecent significant stressors or life changes* Major life stress Death of loved one Job loss Divorce Major illness Surgery Pregnancy/childbirth When did these occur?*Environmental exposures* Live near industrial area Well water Fluoride exposure Heavy metal exposure Mold exposure Current medications/supplements* Diet patterns* Standard American diet Low-carb Vegetarian/Vegan Gluten-free Dairy-free Other Other Diet patterns*Exercise habits*SleepAverage hours per night*Sleep quality* Poor Fair Good Comprehensive Health AssessmentDigestive health* Bloating Gas Constipation Diarrhea Food sensitivities Diagnosed Digestive Conditions*Stress & adrenal function* Chronic stress Difficulty handling stress Feeling "wired but tired" Afternoon energy crash Difficulty waking up Blood sugar regulation* Sugar cravings Afternoon fatigue Shakiness when hungry Energy crashes Pre-diabetes/diabetes Immune system* Frequent Infections Autoimmune Conditions Allergies Chronic Inflammation Hormonal Health* PMS Irregular Periods PCOS Endometriosis Menopause symptoms Fertility issues Thyroid Functional GoalsWhat would feel "optimal" look like for you?Top 3 health goalsGoal 1Goal 1Goal 3 What treatments have you tried?* Conventional medicine only Alternative therapies Supplements Dietary changes other Other Treatments*How motivated are you to make lifestyle changes?*12345678910Date of Form Completion* MM slash DD slash YYYY Consent* I confirm this information is accurate. I agree to this consent. My name represents my signature.*
