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TAQ - Thyroid Assessment Questionnaire

Concerned about your thyroid?

Fatigue
Depression/Anxiety
Unexplained weight changes
Difficulty tolerating heat or cold

A few minutes spent with this brochure may change your life...

This questionnaire was developed by doctors and patients who believe these questions will provide a useful dialogue about the symptoms of thyroid disease.

Once you have completed this questionnaire, if you feel that you may have a thyroid problem, print this form and take it to your physician on your next visit.

Left untreated, thyroid dysfunction can lead to serious health problems, including cardiovascular disease, osteoporosis, anxiety and depression. Early diagnosis is important.

About Thyroid Disease

Thyroid disease affects more than 1 million Canadians and many don't know they have it.

The thyroid gland is a tiny gland, located in front of the windpipe, that regulates every organi in the body through its hormones. When it's not functioning properly you know something is wrong. Unfortunately, you may not know you have a thyroid disorder.

Often the signs and symptoms of thyroid disease can mimic many other conditions. Diagnosis may be clear only after several of the symptoms become apparent.

Thyroid Assessment Questionnaire

1. Do you currently have any of these symptoms?

Palpitations (rapid or forceful heart beat): Yes No
Poor concentration: Yes No
Memory loss: Yes No
Difficulty sleeping: Yes No
Excessive need for sleep: Yes No
Fatigue: Yes No
Weak muscles: Yes No
Sore muscles: Yes No
Agitation/anxiety: Yes No
Depression: Yes No
Dry skin: Yes No
Itchy skin: Yes No
Unusual hair loss: Yes No
Dry hair: Yes No
Cracking nails: Yes No
Infrequent bowel movements or hard stools: Yes No
Frequent bowel movements or loose stools: Yes No
Unexplained weight gain: Yes No
Unexplained weight loss: Yes No
Persistent pain or swelling at the front of the neck: Yes No
Hoarseness: Yes No
Sensation of a lump in the throat: Yes No
Eye pain or double vision: Yes No
Swelling or protrusion of eyes: Yes No
Change in facial appearance: Yes No
Sweating: Yes No
Difficulty tolerating cold: Yes No
Difficulty tolerating heat: Yes No
Hand tremor: Yes No

For Women Before Menopause Only

A. Loss of menstrual periods: Yes No
Irregular periods: Yes No
Excessive menstrual flow: Yes No

B. Have you been pregnant or miscarried during the past 2 years?

Pregnant: Yes No
Miscarried: Yes No

2. Name

3. Were you born in Canada? Yes No
Where?

4. Do you have any family members with diagnosed thyroid disease? Yes No Unsure

If yes, please indicate the diagnosis which applies to them, if known.
Overactive thyroid gland
Underactive thyroid gland
Nodule or enlarged thyroid gland
Thyroid cancer
Unknown thyroid disease
Other

5. Have you ever been diagnosed with a thyroid disease? Yes No

If yes, please indicate.
Overactive thyroid
Underactive thyroid gland
Nodule or enlarged thyroid gland
Thyroid cancer
Other

6. Are you currently being treated for a thyroid disease? Yes No

If yes, please indicate.
Thyroid hormone therapy (eg. Synthroid, Eltroxin, Cytomel)
Antithyroid drug therapy (eg. PTU, Tapazole)
Other

7. Were you ever treated for a thyroid disease in the past? Yes No

If yes, please indicate all that apply.
Thyroid hormone therapy (eg. Synthroid, Eltroxin, Cytomel)
Thyroid surgery
Radioiodine therapy (not the diagnostic scan)
Antithyroid drug therapy (eg. PTU, Tapazole)
Other

8. Do you currently take any herbal remedies or dietary supplements specifically to benefit
your thyroid? Yes No

If yes, please list.

9. Do you have any of the following medical problems?

High blood pressure: Yes No
High cholesterol: Yes No
Heart disease or angina (chest pain): Yes No

10. Do you take any of the following?

Cholestyramine: Yes No
Amiodarone: Yes No
Lithium: Yes No

This Thyroid Assessment Questionnaire has been design by the Thyroid Foundation of Canada.
Funding for this publication was provided by Health Canada.
The opinions expressed in this publication are those of the authors and contributors and do not necessarily reflect the official views of Health Canada.
This publication is available through Knoll Pharma Inc. and the Thyroid Foundation of Canada.

Download TAQ in pdf form