Thyroid Function

The thyroid gland regulates metabolism & hormone function and is important for numerous physiological functions in the body. Please indicate answers below:

1. Do you have a family history of hypothyroidism or other thyroid problems?

Yes
No

2. Is your skin dry without the use of lotion?

Yes
No

3. Do you suffer from constipation?

Yes
No

4. Are your menstrual cycles irregular?

Yes
No

5. Do you have high cholesterol?

Yes
No

6. Do you have low blood pressure?

Yes
No

7. Is your hair dry?

Yes
No

8. Are your nails brittle?

Yes
No

9. Is your hair thinning?

Yes
No

10. Is the outer third of your eyebrows missing or thinning?

Yes
No

11. Does your skin have a yellow tint?

Yes
No

12. Do you sometimes suffer from depression?

Yes
No

13. Do you suffer from mood swings?

Yes
No

14. Do you need caffeine and/or other stimulants to get you going?

Yes
No

15. Do you have low energy levels?

Yes
No

16. Do you have a low sex drive?

Yes
No

17. Do you note any forgetfulness?

Yes
No

18. Do you have difficulty losing weight?

Yes
No

19. Is it easy for you to gain weight?

Yes
No

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