Hypothyroid Self Assessment

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

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All questions marked with a * are mandatory.

Personal Details
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Hypothyroid Assessment

Update your weight

What unit of measurement are you using?: *
Change in weight: *

Update your heart rate


If less that 60 BPM or above 80 BPM when resting, please discuss with your doctor

Update your blood test results

Have you had your blood tested for thyroid in the last 9 months?: *
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Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Providing NHS Services

Grange Road Surgery
Grange Road
Bishopworth
Bristol
BS13 8LD

Telephone: 0117 964 4343

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