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Hypothyroidism review

Hypothyroid Self Assessment
Required fields are labelled
You must be aged 13 or over to complete this form yourself
Who are you completing this form for?
For example, on behalf of a child or dependent
What is your name?
What is your date of birth?
For example, 31 3 1980
What is your sex?
As recorded on your medical record
The one used to register with your GP
Anyone else with access to your email account may see responses sent to you
Please only complete this form if you have been specifically requested to do so. Any submitted forms that have not been requested by a Medical Professional will be voided.
If it is less than 60 or above 80 when resting please discuss this with your doctor
Change in Weight:
Have you had your blood tested for thyroid in the last 9 months?