Thyroid Assessment Questionnaire

Concerned about your thyroid?

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.

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

Thyroid Assessment Questionnaire

    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.

    1. Do you currently have any of these symptoms?
    Yes      No     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

     For Women Before Menopause Only:
     A. Menstrual Change:
    Yes     No     Loss of menstrual periods
    Yes     No     Irregular periods
    Yes     No     Excessive menstrual flow
     B. Have you been pregnant or miscarried during the past 2 years?
    Yes     No     Pregnant
    Yes     No     Miscarried

     2. Name

     3. Were you born in Canada?     Yes     No
    If not, where were you born?

     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

     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

     6. Are you currently being treated for a thyroid disease? Yes No
    If yes, please indicate:

         Thyroid hormone therapy
         Antithyroid drug therapy

     7. Were you ever treated for a thyroid disease in the past? Yes No
    If yes, please indicate all that apply.

         Thyroid hormone therapy
         Thyroid surgery
         Radioiodine therapy (not the diagnostic scan)
         Antithyroid drug therapy

     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?
    Yes No     High blood pressure
    Yes No     High cholesterol
    Yes No     Heart disease or angina (chest pain)
     10. Do you take any of the following?
    Yes     No     Cholestyramine
    Yes     No     Lithium
    Yes     No     Amiodarone

© Thyroid Foundation of Canada

This Thyroid Assessment Questionnaire was designed 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.