Thyroid Health Quiz Question Template for Functional Medicine
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Thyroid Health Quiz Question Template for Functional Medicine
A ready-to-use set of 8 thyroid health assessment questions designed for functional medicine practitioners. This template evaluates hypothyroid and autoimmune thyroid patterns, including cases where labs appear normal but symptoms persist. Patient responses map to three clinical archetypes: Classic Hypothyroid, Autoimmune Thyroid (Hashimoto's Pattern), and Thyroid-Conversion Dysfunction.
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How to Use This Template
Download and Print
Click the "Download as PDF" button above and save the template to your computer. Print copies for your practice or keep a digital reference.
Copy Into Your Assessment Tool
Copy the 8 questions below into any quiz builder, form tool, or assessment platform. Each question includes multiple-choice options and maps to specific clinical archetypes. Modify as needed to fit your clinical approach.
Or Automate With Brevlix
Instead of copying questions manually, Brevlix deploys this thyroid health assessment on your website in minutes. Scoring, archetype mapping, and patient report generation are handled automatically. Customize your branding and go live.
Template Content
Q1: Which of these do you experience regularly? (check all that apply)
☐ Fatigue that doesn't improve with rest
☐ Feeling cold when others are comfortable
☐ Unexplained weight gain or difficulty losing weight
☐ Hair thinning or loss
☐ Brain fog or difficulty concentrating
Q2: Have you been told your thyroid labs are "normal" but you still have symptoms?
☐ Yes — this has happened multiple times
☐ Yes — once
☐ No — my labs match how I feel
☐ I've never had thyroid labs drawn
Q3: Do you have a family history of any of the following? (check all that apply)
☐ Hashimoto's or autoimmune thyroid disease
☐ Hypothyroidism
☐ Other autoimmune conditions
☐ None of the above
Q4: How would you describe your bowel movements?
☐ Regular, daily
☐ Constipated (less than once per day)
☐ Loose or diarrhea-predominant
☐ Alternating between constipation and loose
Q5: Have you noticed changes in any of the following? (check all that apply)
☐ Skin dryness
☐ Nail brittleness
☐ Thinning of the outer third of eyebrows
☐ None of these
Q6: What is your typical body temperature?
☐ Below 97.5°F (36.4°C)
☐ 97.5-98.5°F (36.4-36.9°C)
☐ Above 98.5°F (36.9°C)
☐ Not sure
Q7: Do you currently take thyroid medication?
☐ Yes — but I still have symptoms
☐ Yes — my symptoms are well-controlled
☐ No, I do not take thyroid medication
Q8: Rate your overall energy level on a scale of 1-5.
1 — Severely low
2
3 — Moderate
4
5 — High energy
Clinical Archetypes:
Click the button to open your browser's print dialog. Select "Save as PDF" as the destination to download.
Deploy This Thyroid Health Assessment on Your Website
Brevlix turns this template into a live, interactive assessment. Patients complete it on your website, responses are scored automatically, and they receive an instant personalized health archetype report — all in about 3 minutes.
Start Free →Frequently Asked Questions
What does the thyroid health quiz template assess?
This template evaluates classic hypothyroid symptoms (fatigue, cold sensitivity, weight gain, hair loss, brain fog), lab-symptom discrepancies, family history of autoimmune disease, bowel patterns, skin and nail changes, body temperature, and medication status. The 8 questions differentiate between Classic Hypothyroid, Autoimmune Thyroid (Hashimoto's Pattern), and Thyroid-Conversion Dysfunction.
What if the patient's labs are normal but they have symptoms?
This is directly addressed in Question 2. When patients report normal labs but persistent symptoms, the template maps toward Thyroid-Conversion Dysfunction — a pattern where T4-to-T3 conversion may be impaired, meaning tissue-level thyroid activity is low despite normal serum labs.
Why does the template ask about bowel movements?
Constipation is a hallmark hypothyroid symptom because thyroid hormone regulates gut motility. The bowel pattern question (Q4) helps differentiate between Classic Hypothyroid (constipation-predominant) and other patterns, and informs treatment considerations around gut-thyroid interactions.
How do I use this template in my practice?
Download the PDF, copy the questions into your existing quiz tool, or deploy through Brevlix for an automated solution. Use it as a pre-appointment screening tool to gather structured thyroid health data and identify cases where labs alone don't tell the full story.