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Thyroid Disorders Screening

Demographic Details

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? *

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

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?

Yes No

Are you gaining/losing weight rapidly? *

Yes No

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

Yes No

Do you have constipation? *

Yes No

Do you have Hairfall? *

Yes No

Do you have Dry Skin? *

Yes No

Are you sensitive to heat/cold temperature? *

Yes No

Are you experiencing any voice changes like hoarseness? *

Yes No

Is there any swelling in front of the neck? *

No Swelling present on noticing closely Very large and obvious swelling

Weight *

Height

Cms

Feet

Inches

BMI *

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Thyroid Disorders Screening

Clinic/Hospital/Doctor

Digital

Self

Existing Patient

Others

Corporate

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Thyroid Disorders Screening

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Clinic/Hospital/Doctor

Digital

Self

Existing Patient

Others

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