THYROID Evaluation & SYMPTOMS CHECKLIST Name *FirstLastGender *GenderMaleFemaleAge *Email *Date / Time *SPECIAL RISKS/SYMPTOMS LIST FOR INFANTS *My infant is on soy formula.My infant has family members(parents, siblings) with thyroid disease.My infant has a swollen tongue.My infant has hoarse cry.My infant has cold extrmities.My infant has mottled skin.My infant has low muscle tone.My infant is not eating well.My infant has thick coarse hair that grows low on forehead.My infant has a large soft spot.My infant has had prolonged jaundice.My infant has a herniated belly button.My infant is lethalgic.My infant sleeps most of the time.My infant appears tired even when awake.My infant has persistent constipation.My infant is bloated or full to the touch.My infant has had little or no growth.SPECIAL SYMPTOMS LIST FOR CHILDREN *My child took soy formula as an infant.My child has family members(parents, siblings) with thyroid disease.My child is not keeping up with growth charts for height.My child is having school problem.My child has been diagnosed with attention deficit disorderMy child is having delayed puberty.My child is usually fatigued, exhausted, or sleeping far more than usual.My child is gaining weight inappropriately.My Child severly constipated.My Child is senstive to cold.My Child's hair is rough, coarse, dry, breaking, brittle.My Child's hair is falling out more than usual.My Child's eybrows & eye lashes are breaking out.My Child's skin is rough, coarse, dry, scaly, itchy & thick.My Child's voice has become hoarse, husky & gravelly.My Child is complaining of pains, aches & stifness in various joint, hands & feets.My Child seems depressed.My Child has difficulty conentrating.My Child seems to be losing interest in normal daily activities.My Child seems more forgetful lately.My Child complains of strange feelings in neck or throat or difficulty swallowing.My Child seems to have some sort of fulness or growth in the neck area.My Child gets more frequent infections or infections that lasts longer.My Child is snoring more lately.My Child yawns frequently to get oxygen.My Child has puffiness & swelling around the eyes and face.My Child has wollen feet, hands or eyelids.NameSubmit
