Hypothyroid Self Assessment

During busier periods we may take a little longer to deal with requests, we aim to deal with any queries as soon as possible, prescriptions and sick notes will be issued within 5 days and backdated where required.

If you have recently changed your contact details, please let us know.

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: *

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

Is there any other information that you feel the Clinician should know?

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Hypothyroid Self Assessment

Appropriate Quality Healthcare