Hypothyroid Self Assessment

For many people with an underactive thyroid (Hypothyroidism) taking thyroxine medication is a simple process of taking a standard and stable dose of pills every day for life. Providing you are well and stable we may be able to monitor your health without you visiting the practice.
If this applies to you (and you are not on any other tablets requiring monitoring), then before your medication runs out please complete this assessment and we will review whether we can repeat your medication for another 9-12 months.

Full Name:

Date of Birth:

Phone Number:

Email Address:

Weight: (Please specify Stones/Pounds/Kilos etc)

Pulse: (If it is less than 60 or above 80 when resting please discuss this with your doctor)

Change in weight:
Abnormal weight gain
Abnormal weight loss
About stable weight

Have you had your blood tested for thyroid in the last 9 months?
I can't Remember

I confirm that the information provided is accurate to the best of my knowledge.

I confirm that I am currently within the UK at the time of sending my enquiry.