Hypothyroid Questionnaire 940 E. El Camino Real Sunnyvale, CA 94087 harminder@homeopathicvibes.com www.homeopathicvibes.com Office Phone (408)737-7100 Office Fax (408)737-7102 Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Do you have dry or scaly skin? YesNoDo you get fatigued easier then you used to? YesNoDo you have less than normal energy? YesNoDoes cold temperature bother you more than others? YesNoHave you had an unexplained increase in weight recently?YesNoHave you had an unexplained decrease in weight recently?YesNoHas you hair become drier, more brittle, coarse or falling?YesNoHave your nails become thin or brittle? YesNoHave you had a decrease in the amount of scalp or body hair? YesNoDo you have a decrease in eyebrows toward the side of your face?YesNoIs there a “dirty” or thickened skin appearance of your elbows or knees?YesNoDo you have pallor or paleness of your skin?YesNoHave you ever been told you are anemic? YesNoHave you been told you were B12 deficient or had pernicious anemia?YesNoDo you have a yellow color to your skin, palms, and soles of feet or nails? YesNoHave you noticed a loss of skin pigmentation on your face or breasts?YesNoDo you have decreased sweating?YesNoDo you have any swelling of you face or throat (goiter)? YesNoDo your ankles swell? YesNoHave you ever had protruding eyeballs? YesNoDo your eyes feel dry if the tear-producing gland has been blocked?YesNoDo your eyes ache, look more bulgy, giving you a staring appearance? YesNoDo you get double vision as the muscles become too swollen to work properly at times? YesNoDid you vision ever become blurry and colors appear less vivid?YesNoDoes front of your eyes get red and irritated very often?YesNoHave you ever had pressure in the lower front of your neck or jaw?YesNoHave any of your blood relatives ever had a thyroid condition?YesNoDo you have a problem with constipation?YesNoDo you suffer from generalized muscle and joint pain or cramping?YesNoDo you suffer from muscle cramps?YesNoDo you suffer from muscle weakness? YesNoDo you have headaches? YesNoDo you have mental confusion? YesNoDo you have delayed reflexes?YesNoHave sensed that your tongue is “thickened” or “swollen”? YesNoDo you have problems pronouncing words? YesNoAre you chronically depressed? YesNoHave you ever been told that you cholesterol is too high?YesNoDo you have a slow heart rate (<60)?YesNoDo you have a fast hear rate (>90)? YesNoIf your have taken your Basal Body Temp, record results here. Day 1Day 2 Day 3Day 4Name *FirstLastAgeSexMaleFmaleEmail *EmailSubmit