Hypothyroid Self Assessment

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 without you visiting the practice.

If this applies to you (and you are not on any other tablets requiring monitoring), then before your medication runs out please complete this assessment and we will review whether we can repeat your medication for another 9-12 months.

You will be required to have a blood test to test your thyroid function at least once a year. If you have not had a blood test for this within the last 12 months, please contact reception to arrange this as well as filling out this form.

If we need to contact you regarding the submission of your form, we may respond directly through the website and aim to do this within 5 working days of receipt of your form. You will be notified of any responses via email. Please remember to check your email account’s spam/junk folder.

Hypothyroid Self Assessment

Hypothyroid Self Assessment

Please use this date format: DD/MM/YYYY. Your date of birth is required to verify your identity.
Please let us know your preferred contact number in case we need to contact you.
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.
Please state whether you are recording in Stones/Pounds/Kilos etc.
If it is less than 60 or above 80 when resting please discuss this with your doctor