FREE Thyroid Screen

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Thank you so much for filling this out prior to your appointment. Your responses to the questions below form an important part of the medically developed Thyroid Screening and will assist your practitioner with assessing your symptoms accurately. We really appreciate you taking the time to fill it out

Your Full Name

Your Email

Rate each of your symptoms below on a severity of 0 to 3 (0 = None and 3 = Severe).

HYPOTHYROID SYMPTOMS

1. Tiredness and Sluggishness

2. Dryer Hair or Skin

3. Sleep More Than Usual

4. Weaker Muscles

5. Constant Feeling of Cold

6. Frequent Muscle Cramps

7. Poorer Memory

8. More Depressed

9. Slower Thinking

10. Puffier Eyes

11. Difficulty with Math

12. Hoarse or Deeper Voice

13. Constipation

14. Coarse Hair/Hair Loss/Brittle

15. Muscle/ Joint Pain

16. Low Sex Drive / Impotence

17. Puffy Hands and Feet

18. Unsteady Gait

19. Gain Weight Easy

20. Outer Third of Eyebrows Thin

21. Menses More Irregular

22. Heavier Menses

23. Carpel Tunnel Syndrome

HYPERTHYROID SYMPTOMS

24. Palpitations

25. Insomnia

26. Tachycardia

27. Shakiness

28. Increased Sweating

29. Brittle Nails

30. Loss of Appetite

Contact Info

Sydney CBD (Head Office), Suite 13, level 3, 247 Coward St. Mascot NSW 2020

1300 THYROID (1300 849 764)

info@thelucyroseclinic.com.auEmail Us

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Tuesday 9am-5pm

Wednesday 9am-5pm

Thrusday 9am-5pm

Friday 9am-5pm

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