Exercise: Hypothyroidism Symptom Evaluation
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- Briana Watkins
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2 Assessing Your Thyroid Health Exercise: Hypothyroidism Symptom Evaluation This test will help you determine whether your thyroid gland may be underactive. Read the statements below, decide on the level of severity or frequency of each sign or symptom, and then circle the number that most accurately reflects how that statement applies to you: 0 = None or never 1 = Mild or occasionally 2 = Moderate or often 3 = Severe or always At the bottom of each page, total up the points circled and write the page total. Carry these totals forward to the end of the section. Multiply the number of points in the first section by 2, then add the points from the second section to come up with a grand total My knees are weak or stiff My back or leg aches. Section I ve been diagnosed with fibromyalgia I ve been diagnosed with carpal tunnel syndrome I get strange sounds in my ears: ringing, buzzing, clicking, or rumbling, or sounds of running water I have chronic constipation I ve been losing a lot of hair I rarely perspire, no matter how hot it is or even if I m exercising My heart appears enlarged on an X-ray I ve been diagnosed with chronic fatigue syndrome The ends of my eyebrows (toward my temples) are getting much thinner and shorter I have deep-seated pain between my shoulder blades I have grooves on my fingernails I have a lot of aches and pains in my joints, hands, or feet I get a lot of sinus infections. 29
3 The Women s Guide to Thyroid Health My tongue seems to be getting bigger, and the sides of it are rippled from pressing against my teeth My voice is hoarse or weak a lot of the time I feel uncoordinated and have a tendency to fall for no reason I ve started to talk very slowly, haltingly, and in a monotone I have a skin disorder such as psoriasis, eczema, or vitiligo I have ADHD (attention-deficit/hyperactivity disorder) I have gout My neck is thickening or bulging in the front under my Adam s apple I sometimes have visual hallucinations such as small animals running across the room I have an autoimmune disease such as Crohn s disease, sarcoidosis, lupus, multiple sclerosis, scleroderma, rheumatoid arthritis, Sjögren s syndrome, diabetes, or myasthenia gravis I have Raynaud s syndrome I have emphysema I ve had a hysterectomy I ve been diagnosed with atherosclerosis (heart disease). Total number of points for section 1: Total number of points for section 1: x 2 = Section My fingernails are soft and thin, and they crack and break easily I produce a lot of tartar on my teeth and have to have them cleaned often My neck often gets stiff I ve started to have very heavy periods I m gaining weight and neither diet nor exercise seems to control it I m losing my eyelashes I ve developed asthma My gums bleed easily or get red and swollen and have started to recede. Section 2 page total: 30
4 Assessing Your Thyroid Health I ve had one or more miscarriages I m getting fine wrinkles on my face and hands I sometimes feel as though bugs are crawling on my skin I sometimes get burning sensations in various parts of my body I have ingrown toenails or fungal infections of my toes I have problems with night vision I get dizzy sometimes or have been told I have vertigo I ve developed knock-knees I get sprains easily My stomach is distended and I have a lot of gas I have a drinking or substance abuse problem I smoke cigarettes I don t tolerate alcohol well I have hypoglycemia I have swollen eyelids or swelling under my eyes My lips are pale I find myself clenching my teeth often, especially at night I find myself tapping my foot or jiggling my leg often I ve been diagnosed with temporomandibular joint syndrome I get recurrent ear infections I have a lot of dental problems, including getting new cavities I ve developed allergies I m easily fatigued I have slow reflexes I get very depressed in the winter My lips appear swollen I ve been diagnosed with sciatica I have prematurely gray hair. 31
5 The Women s Guide to Thyroid Health The skin on my legs is rough or scaly, particularly below my knees I have anemia I have diabetes My face is pale My hair is dry and brittle I have a lot of earwax I don t seem to be able to control my rage and fury, and sometimes I lash out at people I have a lot of moles and warts I have elevated LDL cholesterol and/or low HDL cholesterol My feet are getting flatter I have fibrocystic breasts and they get very tender and sore Sex doesn t interest me anymore I get very irritable and moody I m almost always tired no matter how much sleep or rest I get My thoughts are getting strange I m often anxious or agitated I get a lot of headaches My hands and feet feel swollen and it isn t due to weight gain My blood pressure is too high or too low Simple things have become confusing and sometimes overwhelming My PMS symptoms are getting worse I have a hard time concentrating much of the time I m having a hard time getting pregnant or had a hard time getting pregnant My hands and feet get tingling pins-and-needles feelings I ve started to get acne I have flaky, red patches on my face I look older than my age. 32
6 Assessing Your Thyroid Health I have a hard time falling asleep at night I ve been feeling very sad or depressed I seem to get sick a lot and have a hard time bouncing back I have restless legs at night I have heart palpitations and skipped heartbeats It sometimes feels as though I m having a heart attack or panic attack I feel like I m going crazy sometimes I ve had an abnormal Pap test or have been diagnosed with cervical dysplasia My skin has an overall puffy or quilted look; even my back looks puffy My hands and feet are always cold I m extremely bothered by heat and/or cold I seem to have almost no body hair anymore I have hemorrhoids I have a chronically low basal body temperature when measured with a thermometer I bruise easily I get frequent urinary tract or bladder infections I have a weak, soft pulse My face and eyelids are puffy I have incredibly dry skin, especially on my feet My vision has become variable and is sometimes blurry or shaky Sometimes I can t hear well out of one or both ears My skin is yellowish and pale or the whites of my eyes are yellowish I m often breathless, and it s hard to catch my breath even when I m not exerting myself The skin on my upper arms and the front of my thighs appears to be getting thicker when I pinch it My urine is scant and often brightly colored I ve started to have irregular menstrual cycles. 33
7 The Women s Guide to Thyroid Health I have dyslexia I m left-handed I have mitral valve prolapse I have ulcerative colitis I have tendinitis I ve lost my appetite and often food doesn t appeal to me I ve started to choke on small objects or have choking sensations My face has taken on a masklike, expressionless look Any wounds I get are very slow to heal I have a lot of nasal congestion I have nightmares or strange dreams I started my menstrual periods before age ten or after age fifteen My nail beds are pale I ve had pneumonia I find myself yawning a lot I have varicose veins I ve been diagnosed with a frozen shoulder. Section 2 page total: Total number of points for section 2: Total number of points for section 1: Total number of points: Interpreting Your Results If your total is between 10 and 15, you re beginning to show signs of possible hypothyroidism; if your total is between 16 and 21 your deficiency is getting more serious. If your score is over 22, you re most likely experiencing significant thyroid function deficiency (and possibly adrenal imbalance as well). With any of these results, you should have a complete physical, including a thyroid exam and lab tests to measure blood levels of free T3, free T4, TSH, and reverse T3, as well as thyroid antibodies if your doctor feels it s warranted. (See chapter 6 for more on these tests.) Since your thyroid is affected by your other endocrine glands, it is also important to measure levels of FSH, estrogen, progesterone, testosterone, DHEA ( dehydroepiandrosterone), and cortisol. 34
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PATIENT SLEEP QUESTIONNAIRE Name: Date of Birth: Today s Date Primary Care Physician Telephone # Physician ordering test (Other than PCP): Physician s Tel. #: _ Age: Years Height: Feet Inches Weight: Lb
Patient History Questionnaire
Patient History Questionnaire Date: Referred By: Name: DOB: Age: SSN: Home Telephone: Cell Phone: E-mail: Blood Pressure: Weight: Height: (Circle) R or L Handed (Check) Medication List Attached Emergency
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Email Address: Emergency Contact Name and Phone Number: Family Doctor Name and Address:
Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION
Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION Name Date Address City State Zip Home Phone Cell Phone # Work: Email Address Occupation Employer
Northeast Ohio Urogynecology Patient History Intake Form. Last Name First Name Age. Date of Birth Race Referring Physician.
Northeast Ohio Urogynecology Patient History Intake Form Last Name _First Name Age_ Date of Birth Race Referring Physician Reason for Visit: _ Allergies: Preferred Lab (circle): QUEST LABCARE PLUS LABCORP
Eastern Body Therapy
2310 Eastern Body Therapy 6th Avenue San Diego, CA 92101 (619)772-4002 Personal Information Name Date of injury/illness Address: Apt. City State Zip Home phone: ( ) Work Phone: ( ) E-mail: Social Security
The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:
PATIENT INFORMATION (PLEASE PRINT) Patient Name: Nickname: Guardian: Date of Birth: Sex: Address: 2nd Address: Home Phone: Work Phone: Cell Phone: Best Number: License / ID# Contact Email: Emergency Contact:
Personal Health Evaluation
Personal Health Evaluation Note: Information provided on this forms will be held in strict confidence. I. Personal Information Name Age Sex Height Weight Eye Color Phone Number or Skype Number you wish
Health Intake Form. Name: Prefer Name: Date: City: State: Zip Code: Gender: M F. Telephone # (home): (work): (Cell):
Health Intake Form Name: Prefer Name: Date: Address: Age: City: State: Zip Code: Gender: M F Telephone # (home): (work): (Cell): Email Address: Date of Birth: Marital Status: Married Separated Divorced
Re-Exam Questionnaire
Re-Exam Questionnaire Patient Name: Date: The following hi-lighted symptoms are what brought you into our office originally. DIRECTIONS: Please rate ALL hi-lighted symptoms: S = same; B = better; W = worse
City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden
Horowitz Lyme-MSlDS Questionnaire
Horowitz Lyme-MSlDS Questionnaire The Horowitz Lyme-MSlDS Questionnaire is not intended to replace the advice of your own physician or other medical professional. You should consult a medical professional
LAKES INTERNAL MEDICINE
LAKES INTERNAL MEDICINE HEALTH HISTORY QUESTIONNAIRE Please print this and complete and bring to your initial appointment. Today's Date Last Name First Name Middle Initial Date of Birth Male Female Education