Thyroid

Your thyroid gland produces a hormone that tells every cell in your body how fast to work. The rate at which your brain, muscles, intestines and heart function is determined largely by thyroid hormone levels. Too much hormone speeds your system and you can experience anxiety, muscle tension, diarrhea and a pounding heart. Too little hormone (far more common) slows your system and you can experience low moods, brain fog, weakness, fatigue and constipation.
Thyroid blood tests may appear “normal” even when the thyroid function is not.  A careful assessment of patient history and symptoms help to determine factors that may have caused thyroid function to decline, and thyroid test results are used as a backup.

This questionnaire will help determine if your thyroid gland is functioning properly. When the thyroid gland isn’t functioning properly you will notice something is off, but may not realize it’s a thyroid disorder. The signs and symptoms of thyroid disorders can mimic many other conditions.

TAQ – Thyroid Assessment Questionnaire

Concerned about your thyroid?

Symptoms of thyroid disorders include:
Fatigue
Depression/Anxiety
Unexplained weight changes
Difficulty tolerating heat or cold

A few minutes spent with this brochure may change your life…
This questionnaire was developed by doctors and patients who believe these questions will provide a useful dialog about the symptoms of thyroid disease.
Once you have completed this questionnaire, if you feel that you may have a thyroid problem, print this form and take it to your physician on your next visit.
Left untreated, thyroid dysfunction can lead to serious health problems, including cardiovascular disease, osteoporosis, anxiety and depression. Early diagnosis is important.

About Thyroid Disease

The thyroid gland is a tiny gland, located in front of the windpipe, that regulates every organ in the body through its hormones. When it’s not functioning properly you know something is wrong. Unfortunately, you may not know you have a thyroid disorder.
Often the signs and symptoms of thyroid disease can mimic many other conditions. Diagnosis may be clear only after several of the symptoms become apparent.

Top of Form 1

Thyroid Assessment Questionnaire

Palpitations (rapid or forceful heart beat): Yes No
Poor concentration: Yes No
Memory loss: Yes No
Difficulty sleeping: Yes No
Excessive need for sleep: Yes No
Fatigue: Yes No
Weak muscles: Yes No
Sore muscles: Yes No
Agitation/anxiety: Yes No
Depression: Yes No
Dry skin: Yes No
Itchy skin: Yes No
Unusual hair loss: Yes No
Dry hair: Yes No
Cracking nails: Yes No
Infrequent bowel movements or hard stools: Yes No
Frequent bowel movements or loose stools: Yes No
Unexplained weight gain: Yes No
Unexplained weight loss: Yes No
Persistent pain or swelling at the front of the neck: Yes No
Hoarseness: Yes No
Sensation of a lump in the throat: Yes No
Eye pain or double vision: Yes No
Swelling or protrusion of eyes: Yes No
Change in facial appearance: Yes No
Sweating: Yes No
Difficulty tolerating cold: Yes No
Difficulty tolerating heat: Yes No
Hand tremor: Yes No

For Women Before Menopause Only

A. Loss of menstrual periods: Yes No
Irregular periods: Yes No
Excessive menstrual flow: Yes No

B. Have you been pregnant or miscarried during the past 2 years?

Pregnant: Yes No
Miscarried: Yes No

Do you have any family members with diagnosed thyroid disease?

If yes, please indicate the diagnosis which applies to them, if known.
Overactive thyroid gland
Under active thyroid gland
Nodule or enlarged thyroid gland
Thyroid cancer
Unknown thyroid disease
Other

Have you ever been diagnosed with a thyroid disease?
If yes, please indicate.
Overactive thyroid
Under active thyroid gland
Nodule or enlarged thyroid gland
Thyroid cancer
Other

Are you currently being treated for a thyroid disease?
If yes, please indicate.
Thyroid hormone therapy (eg. Synthroid, Eltroxin, Cytomel)
Antithyroid drug therapy (eg. PTU, Tapazole)
Other

Were you ever treated for a thyroid disease in the past?
If yes, please indicate all that apply.
Thyroid hormone therapy (eg. Synthroid, Eltroxin, Cytomel)
Thyroid surgery
Radioiodine therapy (not the diagnostic scan)
Antithyroid drug therapy (eg. PTU, Tapazole)
Other

Do you currently take any herbal remedies or dietary supplements specifically to benefit
your thyroid?