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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


Anemia



Constipation


Hoarseness of voice


Generalized aches & pains



Muscular cramps or stiffness


Sluggishness/lethargy/sleepiness


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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