Thyroid and Metabolism Questionnaire

This questionnaire is confidential! The questions that you answer and the results of this test will only be seen by you and are not sent to our office nor will be reviewed by our office. Each response that you give will be assessed by our exclusive Health Evaluation Program and your results will be given at the conclusion of this test. Please feel free to contact our office if you have any questions or would like additional assistance with your results.

This questionnaire helps you determine the function of thyroid hormone in your body. Regardless if you have had lab tests that say your thyroid is normal or that you may be taking prescription thyroid medication, you still may have problems with metabolism that directly relate to how thyroid hormone is functioning in your body.

Scoring: in front of each question enter the following score:
10 ....... If this is a noticeable issue or significant problem
5 ....... If this is a problem, but not a major issue
2 ....... If this happens every now and then, but you don't notice it too much
0 ....... If you seldom or never have this issue.

Fill out the following form completely and then click on "Get My Results" in order to see the results of your test.

Your Name

0	2	5	10
				1) Are you cold (cold hands/feet)?
				2) Do you have a swelling in the neck area?
				3) Are you overweight? (10 if over 20 lbs, 5 if 10-19 lbs, 2 if 5-9 lbs)
				4) Can you eat very little and still not lose weight (or you gain weight too easily)?
				5) Are you tired all the time?
				6) Do you wake up with headaches/heavy head that wears off as the day progresses?
				7) Do you always need a lot of sleep, and even then you don't feel well rested?
				8) If you sit down during the day do you get tired (energy drops when you stop moving)?
				9) Does your energy significantly drop in the afternoon?
				10) Do you rely on caffeine, nicotine, or some other stimulant to keep your energy going?
				11) Women - Are your moods noticeably worse with your menstrual cycle or transition? 11) Men - Do you lack a morning erection (never get one=10, sometimes=5, occasionally=2)
				12) Does stress cause you to feel irritable too easily (short fuse, low tolerance)?
0	2	5	10
				13) Are you depressed, easily prone to depression, and/or feel less communicative or withdrawn?
				14) Are you prone to depression in the fall or spring?
				15) Does your head feel heavy (and/or your memory/concentration is noticeably declining)?
				16) Is the outside portion of your eyebrows thinning (or gone)?
				17) Do you have dry skin and/or dry hair?
				18) Do you have rough patches of skin on your elbows?
				19) Is your hair falling out (or less body hair in general: head, legs, arms, eyelids, eyebrows)?
				20) Are you prone to constipation (including having to strain to eliminate)?
				21) Do you have numbness in your extremities or have carpal tunnel syndrome?
				22) Are you prone to facial fluid retention, especially around the eyes?
				23) Is your voice hoarse or coarse?
				24) Do you get muscle cramps or have general muscle weakness?
				Do you have high or low cholesterol? ( 10 if over 250 ) ( 5 if 220-249 ) ( 2 if 201-219) (10 if under 140) ( 5 if 141-160 )