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Home > Hypothyroid Self Assessment Form

Hypothyroid Self Assessment Form

For many people with an underactive thyroid (Hypothyroidism) a the daily medication of thyroxine is a simple way to keep the thyroid stable. If you are well and stable we may be able to monitor your health through these assessments and not need a regular face to face consultation.

If you are not on any other medication that needs to be monitored, complete the assessment below before your medication runs out.  We can then review the information and determine if we can repeat your medication for another 9 to 12 months.

You can also use accuRx to submit an online assessment.

Your Details
Assessment Questions
If your resting pulse is below 60 or over 80 contact us to discuss this with a doctor.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.


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Prentis Medical Centre

2 Prentis Road, Streatham, London, SW16 1XU

  • 020 8696 5508
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