Pre-consultation: Thyroid Service

First name *

Last name *

Email *

Phone *

Date of birth *

Which symptoms are you experiencing? *

Fatigue

Weight gain

Cold intolerance

Constipation

Dry skin

Hair loss

Depression

Brain fog

Heavy periods

Muscle aches

Puffy face

Slow heart rate

Palpitations

Anxiety

Weight loss despite good appetite

Tremor

Heat intolerance

Sweating

Diarrhoea

Irregular periods

Insomnia

Irritability

Bulging eyes

Neck swelling

Difficulty swallowing

Hoarseness

None - just want thyroid checked

How long have you had these symptoms? *

Less than 1 month

1-3 months

3-6 months

6-12 months

Over 1 year

How severe are your symptoms? *

Mild - noticeable but not affecting daily life

Moderate - affecting some daily activities

Severe - significantly impacting daily life

Are your symptoms getting worse, stable, or improving? *

Getting worse

Stable

Improving

Have you been previously diagnosed with a thyroid condition? *

No

Yes - hypothyroidism/Hashimoto's

Yes - hyperthyroidism/Graves'

Yes - thyroid nodule

Yes - thyroid cancer

Yes - subclinical hypothyroidism

Yes - subclinical hyperthyroidism

Yes - other

TSH level (if you have a recent result):

Normal range typically 0.4-4.0 mIU/L

When was TSH last tested?

Free T4 level (if you have a recent result):

Normal range typically 10-20 pmol/L

Free T3 level (if you have a recent result):

Normal range typically 3.1-6.8 pmol/L

TPO antibodies (if you have a recent result):

Positive TPO confirms autoimmune thyroiditis

TSI or TRAb antibodies (if you have a recent result):

Positive confirms Graves' disease

Do you have a family history of thyroid disease?

No

Yes

Do you have a family history of autoimmune conditions?

No

Yes

Do you have any other autoimmune conditions?

No

Yes

Do you have coeliac disease?

Coeliac disease affects levothyroxine absorption

No

Yes, diagnosed

Yes, suspected

No, ruled out

Are you currently pregnant or postpartum?

No

Yes - pregnant

Yes - postpartum

Are you planning pregnancy?

Thyroid optimisation is critical - target TSH <2.5 in first trimester

No

Yes - within 6 months

Yes - within 1 year

Yes - timing uncertain

Have you had recent significant illness or surgery?

No

Yes

Have you ever had neck radiation?

No

Yes

Do you take lithium?

Lithium commonly causes hypothyroidism

No

Yes

Do you take amiodarone?

Amiodarone contains iodine and affects thyroid function

No

Yes

Do you take iodine supplements or consume excessive seaweed?

Excess iodine affects thyroid function

No

Yes - iodine supplements

Yes - lots of seaweed

Yes - both

List all your current medications:

Do you take iron supplements?

No

Yes

Do you take calcium supplements?

No

Yes

Do you take biotin supplements?

CRITICAL - biotin interferes with thyroid blood test results. Stop 2 days before testing

No

Yes

What are you hoping for from this appointment? *

New thyroid assessment

Dose adjustment

Second opinion

Understand my results

Switch medication

Pregnancy planning

General thyroid advice

Anything else you'd like us to know?

Here's what you've told us. Have a quick check, then hit send - this means your consultation can focus on what actually matters to you.

Your details

Name

Email

Phone

Date of birth

Current Symptoms

Which symptoms are you experiencing? -

How long have you had these symptoms? -

How severe are your symptoms? -

Are your symptoms getting worse, stable, or improving? -

Thyroid History

Have you been previously diagnosed with a thyroid condition? -

Recent Blood Results

TSH level (if you have a recent result): -

When was TSH last tested? -

Free T4 level (if you have a recent result): -

Free T3 level (if you have a recent result): -

TPO antibodies (if you have a recent result): -

TSI or TRAb antibodies (if you have a recent result): -

Family History

Do you have a family history of thyroid disease? -

Do you have a family history of autoimmune conditions? -

Medical History

Do you have any other autoimmune conditions? -

Do you have coeliac disease? -

Are you currently pregnant or postpartum? -

Are you planning pregnancy? -

Have you had recent significant illness or surgery? -

Have you ever had neck radiation? -

Do you take lithium? -

Do you take amiodarone? -

Do you take iodine supplements or consume excessive seaweed? -

Current Medications

List all your current medications: -

Do you take iron supplements? -

Do you take calcium supplements? -

Do you take biotin supplements? -

Your Goals

What are you hoping for from this appointment? -

Anything else you'd like us to know? -

Anything else for your doctor?