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   Thyroid Questionnaire

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1. Do you experience frequent headaches? yes   no
2. Do you frequently feel groggy or tired when you wake up in the morning? yes   no
3. Do you have dark circles under your eyes? yes   no
4. Do you get sores in your mouth or your lips? yes   no
5. Do you frequently have a sore throat? yes   no
6. Do you have unusually dry skin? yes   no
7. Do you have severe eczema, dandruff, or psoriasis? yes   no
8. Do you ever feel full of pep? yes   no
9. Do you often feel so down in the dumps that nothing could cheer you up? yes   no
10. Do you often feel worn out? yes   no
11. Do you frequently feel downhearted and blue? yes   no
12. Are you always tired? yes   no
13. Do you have a poor memory? yes   no
14. Do you experience severe mood swings and irritability? yes   no
15. Do you have one or two normal easy bowel movements daily? yes   no
16. Do you have excess weight around you midsection? yes   no
17. Do you feel chilly when everyone else is warm? yes   no
18. Have you experienced a decreased interest in intercourse or intimate relations? yes   no
19. Do you catch cold or flu easily? yes   no
20. Do you have pain, aches or stiffness in your muscles without recent strenuous exercise? yes   no
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