Thyroid Function Assessment
Download Thyroid Function Assessment
For each question, select the number that best describes your symptoms:
0 = No or Rarely – You have never experienced the symptom
1 = Occasionally – Symptoms come and go and are linked in your mind to stress, diet, fatigue, or some identifiable trigger
3 = Often – Symptoms occur 2-3 times per week and/or with a frequency that bothers you enough that you would like to do something about it
5 = Frequently – Symptoms occur 4 or more times per week and you are aware of them everyday, or it occurs with regularity on a monthly or cyclical basis
1. Feel cold or chilled – hands, feet, or all over – for no apparent reason.
2. Your upper eyelids look swollen.
3. Muscles are weak, cramp and/or tremble.
4. Poor memory, forgetful.
5. Reaction time seems slowed down.
6. Disinterest in sex, low sex drive.
8. Feel slow-moving, sluggish, low energy, and dull.
9. Dryness, discoloration of skin and/or hair.
10. Thick, brittle nails.
11. Weight gain for no apparent reason.
12. Difficulty losing weight no matter how hard you try.
13. Outer third of your eyebrow is thinning or disappearing.
14. Swelling of the neck.
15. Experience feeling of depression or apathetic moods.
16. Experience hoarse/slow speech.
17. Excessive menstrual flow.
18. Water retention in face and extremities.
19. Low body temperature.
20. Problems with regulating blood sugar.
If you score high in most of these questions, please ask Dr. Sierra to have your thyroid functions evaluated. This can be done with blood studies and body temperature observation. The thyroid gland secretes several life-sustaining hormones that are responsible for major energy production and metabolic activities in every cell in the body. When the levels of these hormones become too low (hypothyroid) or too high (hyperthyroid), cellular functions such as fat metabolism, carbohydrate metabolism, vitamin utilization, sexual functions, sleep, digestion, sex hormone metabolism, etc…are affected severely.
Consider consulting with Dr. Sierra at your next appointment regarding your symptoms and ways to restore your thyroid gland’s functions.