Thyroid Quiz

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Patient Name*

Date of Birth*

Age*

Gender*

Occupation*

Email*

Chief Complaint & Motivation For Visit

What 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 & Metabolism

Fatigue/low energy*

Weight gain (unexplained)*

Difficulty losing weight*

Feeling cold/cold intolerance*

Cold hand and feet*

Slow metabolism*

Mood & Cognitive

Depression/low mood*

Anxiety*

Brain fog/mental sluggishness*

Memory problems*

Difficulty concentrating*

Irritability*

Physical Symptoms

Hair loss/thinning*

Dry skin*

Brittle nails*

Constipation*

Muscle weakness*

Joint pain*

Swelling (face, hands, feet)*

Hoarse voice*

Sleep & Hormonal

Insomnia/sleep disturbances*

menstrual irregularities*

Decreased libido*

Infertility concerns*

When did these symptoms first begin?*

Have symptoms been*

Gradual onset

Sudden onset

Worsening

Stable

Diet patterns*

Standard American diet

Low-carb

Vegetarian/Vegan

Gluten-free

Dairy-free

Other

Other Diet patterns*

Exercise habits*

Sleep

Average hours per night*

Sleep quality*

Poor

Fair

Good

Thyroid Functional Goals

What would feel "optimal" look like for you?

Top 3 health goals

Goal 1

Goal 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?*

Date of Form Completion*

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