Low Thyroid Status

Answer the questions below, using the symptom scale:

0=Never 1=Seldom 2=Occasionally 3=Frequently

4=Infrequently with severe symptoms 5=Almost always

Increase in weight

Constipation

Frequent and lengthy colds

Difficulty conceiving

High blood cholesterol

Always feel cold

Adult acne

Menstrual cramps

Diabetes

Excessive fatigue

Coarse, dry skin or hair

Lack of interest in sex

Insomnia

Lithium Therapy

Your Name

Mentally sluggish

Headaches

Premenstrual symptoms

Hypoglycaemia

Difficulty losing weight

Depression

Water retention

Diminished sweating

Down's Syndrome

Cold hands and feet

Recurrent colds and flu

Periods too heavy, irregular; missed periods

Anaemia or low white blood cell count

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