Hypothyroid Self Assessment If you have been advised by the surgery to submit hypothyroid self assessment please use this form. Name First Last Date of Birth Day Month Year PhoneEmail Enter Email Confirm Email Weight Pulse If it is less than 60 or above 80 when resting please discuss this with your doctorChange 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