Hypthyriodism Self Assessment Form - Birchwood Medical Practice

Hypothyroid Self Assessment

If you have been advised by the surgery to submit hypothyroid self assessment please use this form.

Your Details

Name *

Date of Birth *

Phone Number

Email Address *

Hypothyroid Self Assessment

Weight *

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? *

Yes

I can't remember

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA *

I consent to the practice collecting and storing my data from this form.

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Page last reviewed: 23 October 2019
Page created: 14 May 2020

Hypothyroid Self Assessment

Hypothyroid Self Assessment

Further Information