THYROID FUNCTION QUESTIONAIRE

Do you suffer from any of the following symptoms?

Rate your symptoms below from a scale of 0-3

0-None 1-Mild 2-Moderate 3-Severe

___Tired and sluggish
___Dry hair and skin
___Need for more sleep
___Weak muscles
___Constant feeling cold
___Muscle cramps
___Poor memory
___Depressed
___Slow thinking
___Puffy eyes                                     
___Difficulty with math
___Hoarser/deeper voice
___Muscle /joint pain
___Constipation
___Coarse hair or hair loss
___Low sex drive/impotence
___Puffy hands and feet
___Unsteady gait
___Gain weight easily
___Thinning outer eyebrow
___Menses more irregular
___Heavier menses

TOTAL HYPO SCORE (8)


____

___Tachycardia (Rapid Heart Beat)
___Palpitation (Skipping of Heart Beat)
___Insomnia
___Shakiness
___Increased Sweating
___Brittle Nails
___Loss of Appetite

TOTAL HYPER SCORE (0)


______

If you scored over 8 in the Hypo section or over 3 in the Hyper section we highly recommend you come in for a Thyroflex test. To read more about the Thyroflex test, click here or call us on (09) 849 4488 to make a booking.