Thyroid Disorders Screening

• Demographic Details
  Full Name *

  Enter First name

  Mr. Ms./Mrs. Master Baby

  Age *

  Please Select Date of Birth

  Age must be greater than 0 and less than 125 Years

  Months must be less than 12

  Days must be less than 31

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  Days

  Mnth

  Yrs

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• Thyroid disorder Screening form
  Do you have immediate family history of any of the adjacent diseases? *  

  Please Enter Do you have immediate family history of any of the adjacent diseases?

  Diabetes Hypertension Heart disease Stroke Lipid disorders (Cholesterol) Thyroid disorders PCOD/PCOS Others None

  Do you have history of any of the adjacent diseases? *

  Please Enter Do you have history of any of the adjacent diseases?

  Diabetes Hypertension Heart disease/Stroke Lipid disorders (Cholesterol) Thyroid disorders PCOD/PCOS Nutritional deficiencies (Vitamin B12/D/Calcium/Iron) Others None

  Are you experiencing menstrual cycle irregularities?

  Please Enter Are you experiencing menstrual cycle irregularities?

  Yes No

  Are you gaining/losing weight rapidly? *

  Please Enter Are you gaining/losing weight rapidly?

  Yes No

  Do you experience a lot of mood swings in a day? *

  Please Enter Do you experience a lot of mood swings in a day?

  Yes No

  Do you have constipation? *

  Please Enter Do you have constipation?

  Yes No

  Do you have Hairfall? *

  Please Enter Do you have Hairfall?

  Yes No

  Do you have Dry Skin? *

  Please Enter Do you have Dry Skin?

  Yes No

  Are you sensitive to heat/cold temperature? *

  Please Enter Are you sensitive to heat/cold temperature?

  Yes No

  Are you experiencing any voice changes like hoarseness? *

  Please Enter Are you experiencing any voice changes like hoarseness?

  Yes No

  Is there any swelling in front of the neck? *

  Please Enter Is there any swelling in front of the neck?

  No Swelling present on noticing closely Very large and obvious swelling

  Weight *

  Please Enter Weight

  Height  

  Cms

  Feet

  Inches

  BMI *

  Please Enter BMI

  Pulse

  Please Enter Pulse

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  Submit