THYROID/GLAND BALANCE QUESTIONNAIRE (MEN)
Symptoms are a major factor in determining a hormonal or thyroid imbalance and are the keys to developing an
effective plan of care to create balance.
Please check any of the following symptoms that you are currently or have previously experienced:
1. Physical Symptoms (Low)
□ Weight Loss Resistance
□ Cold feet or hands
□ Sluggish reaction time or reflexes
□ Fatigue (energy drops out during day)
□ Poor Mood or Depression
□ Problems with skin (adult acne/eczema)
□ Hair loss/thinning
□ Brittle/cracked nails
□ Throat, neck, or tongue swelling
□ Little tolerance for exercise
□ No strength increase from exercise
□ High Cholesterol
□ Constipation
□ Digestive Issues
2. Emotional Factors (Low)
□ Frequently “fly off the handle”
□ Startled easily
□ Poor recovery time from illness
□ Dizziness upon standing
□ Low stamina for stressful situations
□ Sweating when nervous
□ “Seems like I’m always stressed out”
□ Very sensitive to chemicals or allergies
□ Low tolerance for alcohol or caffeine
□ Hard to get going in the morning
□ Afternoon Fatigue
□ Salt Cravings
□ Fatigued all day but wired at bedtime
3. Mental Factors (Low)
□ Decreased mental ability or memory
□ Decreased Libido
□ Loss of muscle mass
□ Apathy, less motivation for life
□ Decreased urine flow
□ Increased urinary urges, feeling of pressure
□ Feeling of being “burnt out”
□ Decreased stamina for exercise
□ Decreased stamina for sexual activity
□ Thinning skin, easy to bruise or scratch
□ Joint stiffness/aches not related to arthritis
Physical Symptoms (High)
□ Bulging eyes or “staring gaze”
□ Fast heart rate
□ Tremors in hands
□ Swelling/tenderness in front of neck
□ Panic Attacks
□ Feeling hot/sweating
□ High Energy
□ Unintentional Weight Loss
□ Loose stools
□ Light Periods/missing periods
□ Often feel like “I’ve had too
Much Coffee
Emotional Factors (high)
□ Thinking gets clouded when I’m rushed
□ Swelling in fingers, ankles, limbs, or face
□ Heart Palpitations
□ High Blood Pressure
□ Easy bruising or oily skin
□ Insomnia
□ High Triglycerides
□ Sugar Cravings
□ Muscle weakness
□ Restless legs at night
□ Generalized tension
□ Constant low grade headache
Mental Factors (High)
□ Constantly feel pressured, irritable, or anxious
□ Increased aggressive behavior
□ Excessive body or facial hair
□ Foggy thinking (unable to think clearly)
□ Adult acne or very oily skin
□ Increased loss in scalp hair
□ Elevated cholesterol, especially triglycerides
□ Increased headaches
□ High Blood Pressure
□ Sleep Disturbances (falling asleep/staying asleep)
If you checked more than 3 symptoms in any category, or more than 10 total, ask one of our practitioners about our
comprehensive thyroid and hormone test to investigate clinical and subclinical hormone imbalances that might be
the answer that you have been looking for.
First Health Associates
2010 S. Arlington Heights Rd
Arlington Heights, IL 60005
www.firsthealthassociates.com
Phone: (847) 593-3330
Form adapted from Thyroid Power by Richard Shames, M.D.
general practitioner specializing in thyroid treatment.