Thyroid Function Questionnaire

  1. Do you have family history of hypothyroidism or other thyroid problems?
  2. Is your skin dry without the use of lotion?
  3. Do you suffer from constipation?
  4. Are your menstrual cycles irregular?
  5. Do you have high cholesterol?
  6. Do you have low blood pressure?
  7. Is your hair dry?
  8. Are your nails brittle?
  9. Is your hair thinning?
  10. Is the outer third of your eyebrows missing or thinning?
  11. Does your skin have a yellow tint?
  12. Do you sometimes suffer from depression?
  13. Do you suffer from mood swings?
  14. Do you need caffeine and/or other stimulants to get you going?
  15. Do you have low energy levels?
  16. Do you have a low sex drive?
  17. Do you note any forgetfulness?
  18. Do you have difficulty losing weight?
  19. Is it easy for you to gain weight?
Test score meaning
If you have answered “yes” to 5 or more of these questions, you may have hypothyroidism (low thyroid hormone function) and require thyroid testing. The thyroid gland regulates metabolism and hormone function, and is important for numerous physiological functions in the body.

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