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Crickhowell Group Practice Welcome. Croeso

Levothyroxine questionnaire

BMI

Height (in meters): *

eg. 1.75

Weight (in kilograms): *

eg. 60.6

BMI:

Please note: BMI calculator is only for patients aged 18 and over

Blood pressure

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Please note, if you are unable to provide a blood pressure reading, reception will contact you to arrange a HCA appointment.

Symptoms

Do you have any of the following new or altered symptoms?

Changes to heat tolerance:

Too hot

Too cold

No change

Changes to weight:

Weight gain (unexplained)

Weight loss (unexpected)

No change

Changes to bowel habits:

Constipation

Diarrhoea

No change

Changes to sleep patterns:

Fatigue

Difficulty sleeping

No change

Have you experienced any of the following symptoms?

Palpitations

Chest pain

Fast pulse or higher blood pressure than usual

Anxiety or change in mood

Difficulty concentrating

Hair loss

Dry skin

If you have any other symptoms or feel generally unwell, please describe these below:

You may be advised to make an appointment to discuss this further, or to have additional blood tests.

When do you take your levothyroxine? *

Do you take your dose every day or as prescribed? *

Yes

No

Please provide details:

Do you take any other medications at the same time? *

Yes

No

Please list any other medications that you take regularly, including medications bought over the counter, multivitamins, supplements and herbal products. You may be advised to omit these prior to your blood test.

You do not need to include medications which are prescribed via the surgery

Have you made any significant changes to your diet?

Yes

No

Please provide details:

Additional comments:

Please advise us if you are planning to conceive or are pregnant as your dose may need to be adjusted.

Confirmation: *

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

Consent:

I consent to receiving an SMS response (if required)

If you are human, leave this field blank.