This questionnaire helps you determine the function of thyroid hormone in your body. It does not matter if you have had lab tests that say your thyroid is OK or that you may be taking prescription thyroid medication, you still may have problems with metabolism that directly relates to how thyroid hormone is functioning in your body.
Scoring: in front of each question enter the following score:
10- If this is a noticeable issue or significant problem
5- If this is a problem, but not a major issue
2- If this happens every now and again, but you don’t notice it too much
0- If you seldom or never have this issue
____ 1. Are you cold (cold hands/feet)
____ 2. Do you have swelling in the neck area?
____ 3. Are you overweight? (10 if over 20 lbs., 5 if 10-19 lbs., 2 if 2-9 lbs.)
____ 4. Can you eat very little and still not lose weight (or you gain weight too easily)?
____ 5. Are you tired all the time?
____ 6. Do you wake up with headaches/heavy head that wears off as the day progresses?
____ 7. Do you always need a lot of sleep, and even then, you don’t feel well rested?
____ 8. If you sit down during the day do you get tired (energy drops when you stop moving)?
____ 9. Does your energy significantly drop in the afternoon?
____ 10. Do you rely in caffeine, nicotine, or some other stimulant to keep your energy going?
____ 11. Women- Are your moods noticeably worse with your menstrual cycle or transition?
Men- Do you lack a morning erection (never get one=10, sometimes=5, occasionally=2)
____ 12. Does stress cause you to feel irritable easily (short fuse, low tolerance)?
____ 13. Are you depressed, easily prone to depression, and/or feel less communicative or withdrawn?
____ 14. Are you prone to depression in the fall or spring?
____ 15. Does your head feel heavy (and/or memory/concentration is noticeable declining)?
____ 16. Is the outside portion of your eyebrows thinning (or gone)?
____ 17. Do you have dry skin and/or dry hair?
____ 18. Do you have rough patches of skin on your elbows?
____ 19. Is your hair falling out (or less body hair in general: head, legs, arms, eyelids, eyebrows)?
____ 20. Are your prone to constipation (including having to strain to eliminate)?
____ 21. Do you have numbness in your extremities or have carpel tunnel syndrome?
____ 22. Are you prone to facial fluid retention, especially around the eyes?
____ 23. Is your voice hoarse or coarse?
____ 24. Do you get muscle cramps or have general muscle weakness?
____ 25. Do you have high cholesterol?
If your score is over 100 you have a significant metabolism problem. Thyroid hormone is not working in a proper manner. Thyroid issues are causing other health problems.
If your score is in the 50-100 range, you have a noticeable metabolism problem. Thyroid hormone function in your body is struggling. Steps need to be taken to prevent health issues from magnifying.
If your score is in the 20-49 range, you are showing signs of metabolism wear and tear. The higher your score in this range, the greater the need to take preventative steps to keep your health on track.
If your score is under 20, your metabolism is in good condition.
If you scored above 50 on this questionnaire, further testing would be beneficial. Complete testing is available through my office as a stand-alone Thyroid Panel or as part of a larger, more Comprehensive Hormone Panel. For further information please contact our office @ 604 467 9554 or email @ firstname.lastname@example.org