Hypothyroid Self Assessment

If you have been advised by the surgery to submit hypothyroid self assessment please use this form.

Last Updated: 23/10/2019

Your Details

Name

Date of Birth
For example, 15 3 1984

Day

Month

Year

Phone Number (optional)

Email Address
Hypothyroid Self Assessment

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

No

I can't remember

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA

I consent to the practice collecting and storing my data from this form.

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