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Referred by
Personal Details
Gender
Male
Female
Country*
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua & Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
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Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegowina
Botswana
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Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia (Hrvatska)
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
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El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and Mc Donald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
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Rwanda
Saint Kitts and Nevis
Saint LUCIA
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Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia (Slovak Republic)
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
St. Helena
St. Pierre and Miquelon
Sudan
Suriname
Svalbard and Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania, United Republic of
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
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Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands (British)
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Wallis and Futuna Islands
Western Sahara
Yemen
Yugoslavia
Zambia
Zimbabwe
Job
IT Professional
Engineer
Doctor
Driver
Sales Man
Farmer
Other
Appetite
Normal
Less
More
Bowel Habbits
Regular
Irregular
Urine Quantity
Adequate
Less
More
Sleeping
Normal
Less
More
Dietary Habits
Dietary Habits
Vegetarian
Non Vegetarian
Habits :
Alcohol
Smoking
Tobacco chewing
MENSTRUAL HISTORY
Menstrual Status
Not Applicable
Menstruating
Menopause
Hysterectomy done
Menstruation
Not Applicable
Regular
Irregular
Bleeding
Not Applicable
Excess
Normal
Scanty
Last 3 consecutive menstruation dates
USG Report if any
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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