ADULT THYROID EVALUATION Rate the following from 1-5, with 1 being no problem & 5 being a severe problem. Name *FirstLastGender *GenderMaleFemaleAge *Phone *Email *1-Fatigue1-Fatigue123452-Muscle aches & pains2-Muscle aches & pains123453-Joint pains3-Joint pains123454-Fibromyalgia4-Fibromyalgia123455-Lethargy,or loss of interest in daily activities5-Lethargy,or loss of interest in daily activities123456-Feelings of Weakness6-Feelings of Weakness123457-Memory Loss7-Memory Loss123458-Concentration Difficulties8-Concentration Difficulties123459-Mental Slugishness9-Mental Slugishness1234510-Low moods10-Low moods1234511-Depression11-Depression1234512-Cold Hands & feets12-Cold Hands & feets1234513-Tendency towards constipation13-Tendency towards constipation1234514-Weight Gain14-Weight Gain1234515-Sweet & carb Cravings15-Sweet & carb Cravings1234516-Low blood sugar/hypoglycemia16-Low blood sugar/hypoglycemia1234517-Menstural Problems17-Menstural Problems1234518-Heavy Bleeding during Menses18-Heavy Bleeding during Menses1234519-Repeated Colds & Flue19-Repeated Colds & Flue1234520-Skin Problems( itching,eczema,psorasis,acne, or coarse, dry scaly skin)20-Skin Problems( itching,eczema,psorasis,acne, or coarse, dry scaly skin)1234521-Low or high blood pressure21-Low or high blood pressure1234522-Donot perspire easily22-Donot perspire easily1234523-Hoarse Voice23-Hoarse Voice1234524-Feeling of fulness in neck24-Feeling of fulness in neck1234525-Sweeling of eyelids/Puffy around eyes25-Sweeling of eyelids/Puffy around eyes1234526-Edema26-Edema1234527-Can see teethindentations around edge of my tongue(enlarged Tongue)27-Can see teethindentations around edge of my tongue(enlarged Tongue)1234528-Hair Loss28-Hair Loss1234529-Coarse Hair29-Coarse Hair1234530-Loss of outer 1/3 of eyebrows30-Loss of outer 1/3 of eyebrows1234531-I have about as many mental & emotional symptons as physical symptons31-I have about as many mental & emotional symptons as physical symptons12345NameSubmit
