Hypothyroid Self Assessment

For many people with an underactive thyroid (Hypothyroidism) taking thyroxine medication is a simple process of taking a standard and stable dose of pills every day for life. Providing you are well and stable we may be able to monitor your health without you visiting the practice.

If this applies to you (and you are not on any other tablets requiring monitoring), then before your medication runs out please complete this assessment and we will review whether we can repeat your medication for another 9-12 months.

If you are human, leave this field blank.

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Please note that your email address will be saved as part of your contact details in your medical records. We may contact you via your email address if you become locked out of your online account and need your password sent, or to send you health questionnaires.

In future we may send you clinical letters via email instead of as a posted letter for speed and to reduce our carbon footprint. You can opt-out of this by telling the Practice.

Weight: *

Pulse: *

If it is less than 60 or above 80 when resting please discuss this with your doctor

Change in Weight:

Abnormal weight gain

Abnormal weight loss

About stable weight

Have you had your blood tested for thyroid in the last 9 months? *

Yes

I can't remember

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Hypothyroid Self Assessment

Self Help