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Barriers to Thyroid Hormone Absorption Questionnaire
To help understand how you take your thyroid, please participate in this survey. Participation is completely voluntary and the information collected will be kept anonymous – this means that your name and other identifying information is not asked for and not used. This information may be used for future publication. You can refuse to participate and such a decision will not affect your medical care at Boston Medical Center, now or in the future. If you have additional questions, please contact Dr. Stephanie Lee at 617-638-8530. This survey should take about ten minutes to complete. THANK YOU FOR YOUR TIME.
How old are you? _______ Sex: Female/Male Height:________ Weight: ________
Which of the following best describes you? (Please circle all that apply)
Alaskan Native American Indian Asian
Black Hispanic Middle Eastern
Mixed Race/Ethnicity Pacific Islander White
Other: __________________
Education: (Please circle level of highest education completed)
Grade School High School College Graduate School
(Primary School) (Secondary School) (University) (Graduate/Professional School)
Marital Status: (Please circle one)
Divorced Married Separated Single
Annual Household Income: (Please circle one)
<$20,000 $20,001-$50,000 $50,001-$100,000 >$100K
 
 
 
1. How do you rate your health? (Please check one box)
 
Excellent
 
Good
 
Fair
 
Poor
 
 
 
2. Which of the following thyroid hormones are you taking? (Please circle)
 
a) Armour Thyroid
 
b) Cytomel
 
c) Levothyroxine
 
d) Levoxyl
 
e) Liothyronine
 
f) Synthroid
 
g) Tirosint
 
h) Unithroid
 
i) Other:
 
 
 
 
3. What is the daily dose of your current thyroid hormone? (Please circle one)
 
a) 5
 
b) 10
 
c) 50
 
d) 75
 
e) 88
 
f) 100
 
g) 112
 
h) 125
 
i) 137
 
j) 150
 
k) 175
 
l) 200
 
m) 300
 
n) Other:
 
 
 
 
4. Why are you taking the thyroid hormones? (Please circle)
 
a) Fertility
 
b) Goiter/Nodule
 
c) Hypothyroidism
 
d) Thyroid cancer
 
e) Thyroidectomy
 
f) Psychiatric/mood problems
 
g) Other:
 
 
 
 
5. Did you have to change your normal lifestyle for the thyroid hormone treatment?
 
No
 
Yes
 
Minimal – does not bother me
 
Moderate – I need to think about or treat the problem every day
 
Severe – My life is much worse because of the thyroid treatment
 
 
 
6. Have you been specifically instructed NOT to take the thyroid hormones with food?
 
Yes
 
No
 
 
 
7. Have you been specifically instructed NOT to take the thyroid hormones with calcium?
 
Yes
 
No
 
N/A: I do not take calcium
 
 
 
8. Have you been specifically instructed NOT to take the thyroid hormones with iron?
 
Yes
 
No
 
N/A: I do not take iron
 
 
 
9. What type of liquid do you take with your thyroid hormone?
   
 
 
 
10. What volume of liquid do you consume with your thyroid hormone? (Please circle one)
   
 
 
 
11. If you take your thyroid hormone at bedtime, do you snack after dinner?
   
 
 
 
12. Has your doctor changed your thyroid hormone dose in the last couple years? (Please circle one)
 
Never
 
Rarely
 
Sometimes
 
Often
 
All the time
 
 
 
13. Do you forget to take thyroid hormones?
 
Never
 
Rarely
 
Sometimes
 
Often
 
All the time
 
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