1.
Do you have a thyroid disorder?
Yes
No
2.
Are you
Hypothyroid (underactive thyroid)
Hyperthyroid (overactive thyroid)
Euthyroid (normal TSH)
Don't know
3.
Have you or someone you know been diagnosed with
Graves' Disease
Hashimoto's thyroiditis
Silent thyroiditis (postpartum)
Thyroid cyst
Goiter
Hot solitary nodule (toxic adenoma)
Cold solitary nodule
Solitary nodule, waiting on tests/results
None of these
4.
If you have a goiter, it is
Non-toxic diffuse (euthyroid, simple)
Diffuse toxic (Graves' Disease)
Toxic nodular, multinodular (Plummer's Disease)
Unknown, waiting on tests/results
Not applicable
5.
If you have been diagnosed with thyroid cancer, the type is
Papillary
Follicular
Medullary
Undifferentiated (anaplastic)
Unknown, waiting on tests/results
Not applicable
6.
In your family
There is a history of thyroid disorders
No one has ever had thyroid problems
Someone may have had a thyroid problem
Don't know
7.
Do you think that your thyroid condition may have been previously misdiagnosed?
Yes
No
Maybe
8.
My age group is
15 and under
16 to 21
22 to 35
36 to 45
46 to 55
56 to 65
66 to 75
75 and over
9.
You are
Male
Female
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