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

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Hypothyroid Self Assessment

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