Thyroid Review

Thyroid Review

Please note that you will be asked to provide your latest blood pressure reading, height and weight.

Please complete this section if you are completing the form on behalf of someone else.

About you (The patient)

Name  Required
Date of Birth  Required
Address  Required
What is your sex assigned at birth?  Required

About Your Condition

Have you been diagnosed with an overactive thyroid (hyperthyroidism)?  Required
Have you been diagnosed with an underactive thyroid (hypothyroidism)?  Required
Do you know what treatment you are taking for your thyroid and what dose?  Required
Have you had a blood test for your thyroid in the last month?  RequiredIf no, please arrange to have this done.
Have you had any weight loss?  Required
Have you had a change in bowel habit?  RequiredFor example, going for a number two more often than usual.
Do you feel like your heart is going faster or slower, or that it's missed a beat?  Required
Do you feel your thyroid medication is managing your symptoms?  Required
Are you planning to get pregnant soon (in the next 3 months)?  Required
Are you pregnant now?  Required
Please answer this section if you answered YES to the above question.
Are you breastfeeding?  Required
What else would you like to tell us?
Privacy Protection  Required

Additional Information

Carers

Chaperoning

GDPR, Data Processing and Subject Access Request (SAR)

Infection Control

Long Term Conditions

Summary Care Records

Zero Tolerance Policy

Non-NHS Services

Patient Participation Group

Responsibilities

Talking Saves Lives

Winter Health

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Complaints Policy