Thyroid Screening Questionnaire

Full Name

Date Picker

Put a check by the following statements that apply to your family history, your personal history, and the symptoms that you may have.

History

My family (parent, sibling, child) has a history of thyroid disease

I’ve had a thyroid problem (i.e., hyperthyroidism, Graves’ disease, Hashimoto’s thyroiditis, post-partum thyroiditis, goiter, nodules, thyroid cancer) in the past

A member of my family or I have currently or in the past been diagnosed with an autoimmune disease

I have had radiation treatment to my head, neck, chest, tonsil area, etc.

I grew up, live, or work near or at a nuclear plant

Women: I have a history of infertility or miscarriage