Hypothyroid Self Assessment Review

For many people with an underactive thyroid (Hypothyroidism) taking thyroxine medication is a simple process of taking a standard and stable dose of pills every day for life. Providing you are well and stable we may be able to monitor your health with an annual blood test and answering a few questions, saving you time, and us some appointments for other patients needing to see us.

If this applies to you (and you are not on any other tablets requiring monitoring), then before your medication runs out please fill in this form and submit and we will review whether we can “automatically” review your medication for another 9-12 months.

Obviously if you are not well we want to see you to assess the situation.

Please Note – once you have submitted this information, any reply or acknowledgement from us will be sent to the email address you provide at top of the form. This response may include personal and sensitive information about you. We therefore strongly advise that you provide a personal email address that only you have access to. If you do not wish for us to communicate with you via email, please do not use this form and call us instead.

Hypothyroid Self Assessment Form

Hypothyroid Self Assessment Form

Please use this date format: DD/MM/YYYY.
This email address will be used for all correspondence relating to this request. Please be aware that if anyone else has access to this email address that they may see responses sent to you.
If it is less than 60 or above 80 when resting please discuss this with your doctor
Change in Weight:
Have you had your blood tested for thyroid in the last 9 months? *