Hypothyroid Self Assessment

Patients should only complete this form if advised to do so by a clinician.

If you are human, leave this field blank.

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Weight: *

Pulse: *

If it is less than 60 or above 80 when resting please discuss this with your doctor

Change in Weight:

Abnormal weight gain

Abnormal weight loss

About stable weight

Have you had your blood tested for thyroid in the last 9 months? *

Yes

I can't remember

Important -

We will be contacting you over the next couple of weeks to invite you to have your first Covid vaccination at Cheltenham East Fire Station. You will also receive a text from the... Find out more

Important -

Our telephone system is currently down through technical issues. If you need to contact us please use the practice's "Message" facility on our website. Thank you

Important -

We understand that the Covid 19 vaccination programme invite system is causing some confusion, and thought it may be helpful to clarify how this is working. There are currently ... Find out more

Important -

This Webpage letter is for people already booked in to have their 2nd coronavirus vaccine after Monday 4 January 2021 Rescheduling your second coronavirus (COVID-19) vaccine appoi... Find out more

Important -

We are delighted to announce our intention to merge with the Portland Surgery on 1st July 2021. Following discussion with GPs and staff at the Portland Surgery about our strength... Find out more

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Hypothyroid Self Assessment

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