Hypothyroidism review

Full Name:

Date of Birth:

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

Phone Number:

If you do not have a phone number, please put N/A.

Email Address:

Please specify the ethnic group the patient belongs to: *

Please specify: *

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

No

I can’t remember

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