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Follow-Up Form

NOTE!
You will be asked to provide detailed information about your body parameters, hypothyroid and depression symptoms, medications and supplements that you use.  Filling out the form can take up to 10 minutes.

Body parameters

NOTE!

  • Blood pressure and pulse must be measured at rest.

  • Waist circumference should be measured at the level of the navel.

Calculated Results
BMI
Under 18.5
Underweight
18.5 - 24.9
Normal
25 - 29.9
Overweight
30 and over
Obese
WHR
Health risk
0.95 or lower
Low
0.96 - 1.0
Moderate
1.0 or higher
High

Hypothyroid Signs and Symptoms Questionnaire (HSS)

Which of the following symptoms apply to you AT THIS TIME?

For symptoms that do not apply, please mark “None”.

Dry skin

Fatigue

Weight gain

Cold intolerance

Muscle stiffness

Puffiness

Early awakening

Memory loss

Feeling blue

Total score:

The implications of the scores are as follows:

  • 9-21 no significant hypothyroid symptoms

  • 22-28 mild hypothyroid symptoms

  • 29-35 moderate hypothyroid symptoms

  • 36-45 severe hypothyroid symptoms

Patient Health Questionnaire (PHQ-9)

Over the LAST 2 WEEKS, how often have you been bothered by any of
the following problems?

For problems that do not apply, please mark “Not at all”.

Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

Trouble falling or staying asleep, or sleeping too much

Feeling tired or having little energy

Poor appetite or overeating

Feeling bad about yourself

(feeling that you are a failure or have let yourself or your family down)

Trouble concentrating on things

(such as reading the newspaper or watching television)

Moving or speaking so slowly that other people could have noticed or the opposite – being so fidgety or restless that you have been moving around a lot more

Thoughts that you would be better off dead, or of hurting yourself in some way

If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?

Total score:

The implications of the scores are as follows:

  • 5-9 minimal depression symptoms

  • 10-14 mild depression symptoms

  • 15-19 moderately severe depression symptoms

  • 20-27 severe depression symptoms

Please list ALL Medications and Supplements that you use AT THIS TIME.

If not applicable, leave blank.

Medications
Dose

(mg., pill, etc.)

Times Per Day or Week

(# TPD or # TPW)

Supplements
Dose

(mg., pill, etc.)

Times Per Day or Week

(# TPD or # TPW)

Please inform of any changes in your general health and lifestyle after your previous consultation.

You have successfully submitted your Follow-Up form.

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