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Personal Details
GRADATION OF SYMPTOMS
Difficulty in swallowing*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Always-Score 4
Difficulty in breathing*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Hoarseness of voice*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Enlarged thyroid*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Palpitation/Racing heart*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Preference for heat*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Preference for cold*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Excessive sweating*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Weight gain*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Weight loss*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Puffiness of face*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Oedema in legs*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Hair fall*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Muscle ache or cramps*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Dry skin*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Brittle Nails*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Brittle/thinning/split hair*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Tiredness or weakness*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Increased or decreased frequency of passing stools*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Bloating stomach*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Constipation*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Poor appetite*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Anxiety*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Irritability*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Poor concentration*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Depressed mood*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Memory problems*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Loss of sleep*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Heat intolerance*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Cold intolerance*
Never-Score 0
Rarely-Score 1
Sometimes-Score 2
Frequently-Score 3
Mostly-Score 4
Always-Score 5
Latest Thyroid Function Test result with date
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