Required field(s) are indicated by * Hypothyroid Self Assessment Hypothyroid Self Assessment If you are human, leave this field blank. You have not agreed to share your data with this website, please either try to login again and grant the website access or alternatively fill out the form below. To proceed, you can either use NHS login, which will retrieve your details and will pre-populate the form below: Continue to NHS login or continue without NHS login and complete the form below: About you Your First Name(s): * As it appears on your passport. Your Last Name: * As it appears on your passport. Postcode: * The one used to register with your GP. Your Date of Birth: * Your date of birth is required to verify your identity. Sex: * Male Female Other As on your medical record. As on your medical record. Your Phone Number: * This phone number will be used for all correspondence relating to this request. Your Email: * This email address will be used for all correspondence relating to this request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you. Please continue completing the form below Weight: * Pulse: * If it is less than 60 or above 80 when resting please discuss this with your doctor Change in Weight: Abnormal weight gain Abnormal weight loss About stable weight Have you had your blood tested for thyroid in the last 9 months? * Yes No I can't remember Submit