Hypothyroid Self Assessment Form Hypothyroid Self Assessment If you have been advised by the surgery to submit hypothyroid self assessment please use this form. Name First Last Please enter your full legal nameDate of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please enter your Date of Birth in the format DD/MM/YYYYPhone Number OptionalEmail Address Hypothyroid Self AssessmentPlease fill out the form belowWeightPulse (If it is less than 60 or above 80 when resting please discuss this with your doctor)Change in Weight: Abnormal weight gain Abnormal weight loss About stable weight Have you had your blood tested for thyroid in the last 9 months? Yes No I can’t remember Consent I consent to the practice collecting and storing my data from this form.THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA