Name *

Age in Years *

Sex *

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Please read each question, select yes/no. Provide any information you would like to share.

Is there any weight gain?

Puffiness of body features

Loss of appetite

Dry and coarse skin

Too much/minimal/absent sweating



Hoarseness of voice

Generalized aches & pains

Muscular cramps or stiffness


Heaviness in body/tiredness

Premature aging symptoms like hair loss

Cold intolerance

Excessive intake of water

Is there any dizziness

Is there any giddiness

Is there constantly headache

Is there any heaviness or unwanted sounds from ears?

Is there any cold and cough?

Is there any cyst?

Are there any black patches on face?

Is there any abnormality in breathing?

Reports of T3, T4 & TSH.

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