ISLAMIA COLLEGE, PESHAWAR (ICP)

DEPARTMENT OF ZOOLOGY
THYROID GLAND HEALTH ASSESSEMENT QUESTIONARE

NAME………………………………………………… F/name ……………………………………………..

Gender…………………………Age………………. Married/Unmarried…………………………

Address…………………………………………………………………………………………………......

………………………………Urban/Rural area……………………………………………………………..
Contact No……………………………………………………………………………………………………………………………………………………………

TODAY’S DATE……........../………………/………………….
DAY MONTH YERA

T3 Level………………….. …………………LH Level………………………………………………………

T4 Level…………………. …………………....progesterone level……………..…….....................................
Glucose level……………..TSH Level………….FSH Level…………Estrogen/androgen level…………….
Other hormonal level……………….. Diagnostic period……………………………………………………..

Which of the following conditions do you i. Tremors

experience most (hypothyroidism): 2. Are you diabetic, if yes then please

a. Cold intolerance mention the effected period of your

b. Weight gain or inability to lose diabetes?

weight …………………………………………

c. Slow heart rate 3. Which type of diabetes you

d. Fatigue have.
e. Dry hair and skin
f. Depression a. Type 1 DM
g. Goiter b. Type 2 DM
h. hair loss 4. What is the condition of your neck.
i. constipation a. Grade 1: Neck thickening,
j. heavy menstrual periods moves upward during
1. Do you have the following signs and swallowing.
symptoms? b. Grade 2: Neck swelling and
a. Irritability pain
b. Anxiety c. Normal
c. Restlessness 5. Do you have the following signs and
d. Trouble concentrating symptoms?
e. Diarrhea a. visual difficulty,
f. Sudden weight loss b. Double vision,
g. Fast or irregular heartbeat c. Blurred vision,
h. Increased body temperature that d. Change of voice
often leads to excessive sweating e. Painful swallowing,
 f. Difficulty swallowing
6. Do have a history of miscarriage? a. …………………………
(Female) …………………

a. Yes b. …………………………
b. No ………………..
7. Do you have a problem of infertility?
12. How are your eyes?
a. Yes
a. Bulging eyes (exophthalmos)
b. No
b. Gritty sensation in the eyes.
8. Do you have an abnormal menstrual c. Pressure or pain in the eyes.
pattern? d. Puffy or retracted eyelids.
a. Longer e. Reddened or inflamed eyes.
b. Heavier f. Light sensitivity.
c. More frequent g. Double vision.
9. I have had radiation treatment to my. h. Vision loss.
a. Head 13. Have you ever had an event in your life
b. Neck, that cause thyroid disease?
c. Chest a. Yes
d. Tonsil area b. No
10. Has anyone in you immediate family had
thyroid disease? 14. Has anyone in you immediate family had
a. Monozygotic thyroid disease?
b. Dizygotic
Father………….Mother……………..

11. Which type of treatment prescribed by

Grandfather………….Grandmother………..
doctor for thyroid disease?
Brother………………Sister…………
Sons………………….daughter………