Get Your Life Back!Get Your Life Back! - thyroidu.comthyroidu.com/wp-content/uploads/2012/04/Get-Your-Life-Back-Thyroid...1 ©2011 Kim Wolinski, MSW “Dr. DeClutter” Get Your Life

__________________________________________________________________________________________________________________________________

1

©2011 Kim Wolinski, MSW “Dr. DeClutter” Get Your Life Back! Reset Your Thyroid Health FORMS www.ThyroidU.com [email protected] 303.485.5280

Get Your Life Back!Get Your Life Back!Get Your Life Back!Get Your Life Back! Reset Your Thyroid HealthReset Your Thyroid HealthReset Your Thyroid HealthReset Your Thyroid Health An organized guide to my health and wellness by Kim Wolinski, MSW “Dr. DeClutter”

This is one of two PDFs: FORMS-PDF-2. These are the FORMS that will help you stay organized with yourself and your healthcare practitioner while you are in your initial treatment for your thyroid problems and long after. The explanation of these FORMS is in the MANUAL-PDF.

PRINT these templates to use for your first consult with your doctor, and all future appointments to track how you are feeling and if the symptoms from your thyroid problem are getting better or worse. 3-HOLE PUNCH and put into a 3-RING BINDER Print a second COVER PLATE from the Manual PDF and insert in the front of your binder.

Print a second This binder belongs toThis binder belongs toThis binder belongs toThis binder belongs to template from the Manual PDF and put in as page 1.

DO NOT FORWARD OR COPY FOR OTHERSDO NOT FORWARD OR COPY FOR OTHERSDO NOT FORWARD OR COPY FOR OTHERSDO NOT FORWARD OR COPY FOR OTHERS Please do not forward PDFs or copy for others. If this system will help someone you know please give them my website link where they can purchase their personal copy! Thank you, Kim. http://thyroidu.com/bookstoreresources/ If your healthcare practitioner is interested in using this system with other patients, have them contact me at [email protected] or 303.485.5280.

Thyroid Health PlanThyroid Health PlanThyroid Health PlanThyroid Health Plan users say,users say,users say,users say,

“The forms in Get Your Life Back Thyroid Health Plan made a

huge difference in how my doctor dealt with me. She could see

exactly where I was each week and how I was feeling, even

when I was unsure how the week or two since our last

appointment was. It was all there in black and white. She said

that it was one of the best patient experiences she’d had in her

18 years of practice because I brought her all the truth about

what I’ve been going through and she could understand and

prescribe my supplements better. Thank you so much. I’m doing

so much better now and still using these forms every day!”

~ Carol, Engineer, Birmingham, AL

“I’m an organized person, but your forms helped make my life

so much easier and calmer while dealing with the overwhelming

symptoms of my thyroid problems. My doctor was really

impressed with my binder! Thank you, Kim for doing this for

me, for all of us. I hope your health continues to get better and

better too.”

~Beverly, Teacher, Dallas, TX

__________________________________________________________________________________________________________________________________

2


CCCCONTENTS:ONTENTS:ONTENTS:ONTENTS: FORMS ONLYFORMS ONLYFORMS ONLYFORMS ONLY (Hole punch; put in 3 ring binder for ongoing use)

You can print the whole pdf and review with the Manual, or look through it and leave some that are noted in red not to print as they are instructions only.

HEALTHCARE PRACTITIONER HEALTHCARE PRACTITIONER HEALTHCARE PRACTITIONER HEALTHCARE PRACTITIONER andandandand PHARMACY INFORMATIONPHARMACY INFORMATIONPHARMACY INFORMATIONPHARMACY INFORMATION FORMSFORMSFORMSFORMS

HEALTHCARE PRATITIONER / PHARMACY INFORMATION ........................................................................................................ 3

CURRENT PRESCRIPTIONS / MEDICATIONS ............................................................................................................................... 4 VITAMINS / MINERALS / ALTERNATIVE MEDICINES & SUPPLEMENTS........................................................................................ 5 AUTOIMMUNE DISEASE: FAMILY TREE CHECKLIST ................................................................................................................. 6-8

HYPOTHYROIDISM SYMPTOM CHECKLIST FOR DOCTOR CONSULTATION .......................................................................... 9-13 HYPERTHYROIDISM SYMPTOM CHECKLIST FOR DOCTOR CONSULTATION ...................................................................... 14-17 FYBROMYALGIA SYMPTOM CHECKLIST FOR DOCTOR CONSULTATION ............................................................................ 18-20 HYPOTHYROIDISM DOCTOR APPOINTMENT / SYMPTOM WEEKLY CHECKLIST ................................................................. 21-24 HYPERTHYROIDISM DOCTOR APPOINTMENT / SYMPTOM WEEKLY CHECKLIST ................................................................ 25-27

FOOD & EATING DOCUMENTATION (F.E.D.) Forms: Use for daily documentation and for weekly meal planning .................. 28

HYPOGLYCEMIA SYMPTOM CHECKLIST FOR DOCTOR CONSULTATION ........................................................................... 30-32 HIGH BLOOD SUGAR / INSULIN RESISTANCE CHECKLIST FOR DOCTOR CONSULTATION ..................................................... 33 DAILY MEDICATION AND SUPPLEMENT CHECKLIST ........................................................................................................... 34-35 WATER LOG ............................................................................................................................................................................. 36 EXERCISE PLAN and LOG .................................................................................................................................................... 37-38 PRACTITIONER APPOINTMENT LOG ........................................................................................................................................ 39 MASTER PRACTITIONER APPOINTMENT LOG .......................................................................................................................... 40 LAB TESTS LOG ........................................................................................................................................................................ 41 INSURANCE COMPANY / BILLINGS LOG — OVERALL DOCUMENTATION LOG ........................................................................ 42

__________________________________________________________________________________________________________________________________

3


HEALTHCARE PRACTITIONER / PHARMACY INFORMATIONHEALTHCARE PRACTITIONER / PHARMACY INFORMATIONHEALTHCARE PRACTITIONER / PHARMACY INFORMATIONHEALTHCARE PRACTITIONER / PHARMACY INFORMATION You can staple business cards here to simplify.

Doctor/Practitioner Doctor/Practitioner Business/Office Name Phone# Phone# Fax# Email Address

Pharmacy Pharmacist Phone# Phone# Fax# Email Address

__________________________________________________________________________________________________________________________________

4


CURRENT CURRENT CURRENT CURRENT PRESCRIPTIONSPRESCRIPTIONSPRESCRIPTIONSPRESCRIPTIONS / MEDICATIONS (Thyroid Medications First/ MEDICATIONS (Thyroid Medications First/ MEDICATIONS (Thyroid Medications First/ MEDICATIONS (Thyroid Medications First)))) Some medicines can interfere with the absorption of thyroid medicines. Document everything.

Medicine Date Started Dosage Times Per Day

Purpose Affect on you. Is it helping?

__________________________________________________________________________________________________________________________________

5


VITAMINSVITAMINSVITAMINSVITAMINS //// MINERALSMINERALSMINERALSMINERALS //// ALTERALTERALTERALTERNNNNATIVE MEDICINES & SUPPLEMENTSATIVE MEDICINES & SUPPLEMENTSATIVE MEDICINES & SUPPLEMENTSATIVE MEDICINES & SUPPLEMENTS

Some vitamins and supplements can interfere with the absorption of thyroid medicines. Document everything.

Supplement Date Started Dosage Times Per Day

Purpose Affect on you. Is it helping?

__________________________________________________________________________________________________________________________________

6


AAAAUTOIMMUNE DISEASEUTOIMMUNE DISEASEUTOIMMUNE DISEASEUTOIMMUNE DISEASE Family TreeFamily TreeFamily TreeFamily Tree ChecklChecklChecklChecklistististist

I haveI haveI haveI have FatherFatherFatherFather MotherMotherMotherMother A GrandparentA GrandparentA GrandparentA Grandparent OthersOthersOthersOthers Related Related Related Related by Bloodby Bloodby Bloodby Blood: Aunts, : Aunts, : Aunts, : Aunts, Uncles, SiblingsUncles, SiblingsUncles, SiblingsUncles, Siblings

1. Achlorhydra AI Active Chronic Hepatitis

2. Addison's Disease

3. Alopecia Areata

4. Amyotrophic Lateral Sclerosis (ALS, Lou Gehrig's

Disease)

5. Ankylosing Spondylitis

6. Anti-GBM Nephritis or anti-TBM Nephritis

7. Antiphospholipid Syndrome

8. Aplastic Anemia

9. Arthritis (over 100 kinds)

10. Asthma

11. Atopic Allergy

12. Atopic Dermatitis

13. Autoimmune Inner Ear Disease (AIED)

14. Autoimmune Lymphoproliferative Syndrome (ALPS)

15. Balo Disease

16. Behcet's Disease

17. Berger's Disease (IgA Nephropathy)

18. Bullous Pemphigoid

19. Cardiomyopathy

20. Celiac Disease/Gluten Intolerant

21. Chronic Fatigue Immune Dysfunction Syndrome

(CFIDS)

22. Churg Strauss Syndrome

23. Cicatricial Pemphigoid

24. Cogan's Syndrome

25. Cold Agglutunin Disease

26. Colitis

27. Cranial Arteritis

28. CREST Syndrome

29. Crohn's Disease

__________________________________________________________________________________________________________________________________

7


30. Cushing's Syndrome

31. Dego's Disease

32. Dermatitis

33. Dermatomyositis

34. Devic Disease

35. Diabetes, Type 1

36. Diabetes, Type 2

37. Dressler's Syndrome

38. Discoid Lupus

39. Eczema

40. Essential Mixed Cryoglobulinemia

41. Eosinophilic Fasciitis

42. Epidermolysis Bullosa Acquisita

43. Evan's Syndrome

44. Fibromyalgia

45. Fibromyositis

46. Fibrosing Alveolitis

47. Gastritis

48. Giant Cell Artertis

49. Glomerulonephritis

50. Goodpasture's Disease

51. Grave's Disease (Hyperthyroid)

52. Guillian-Barre Syndrome

53. Hashimoto's Thyroiditis (Hypothyroid)

54. Hemolytic Anemia

55. Henoch-Schonlein Purpura

56. Hepatitis

57. Hughes Syndrome

58. Idiopathic Adrenal Atrophy

59. Idiopathic Pulmonary Fibrosis

60. Idiopathic Thrombocytopenia Purpura

61. Inflammatory Demylinating Polyneuropathy

62. Irritable Bowel Syndrome

63. Kawasaki's Disease

64. Lichen Planus

65. Lou Gehrig's Disease

66. Lupoid Hepatitis

67. Lupus

__________________________________________________________________________________________________________________________________

8


68. Lyme Disease

69. Meniere's Disease

70. Mixed Connective Tissue Disease

71. Multiple Myeloma

72. Multiple Sclerosis (MS)

73. Myasthenia Gravis

74. Myositis

75. Ocular Cicatricial Pemphigoid

76. Osteoporosis

77. Pars Planitis

78. Pemphigus Vulgaris

79. Polyglandular Autoimmune Syndromes

80. Polymyalgia Rheumatica (PMR)

81. Polymyositis

82. Primary Biliary Cirrhois

83. Primary Sclerosing Cholangitis

84. Psoriasis

85. Raynaud's Phenomenon

86. Reiter's Syndrome

87. Rheumatic Fever

88. Rheumatoid Arthritis

89. Sarcoidosis

90. Scleritis

91. Scleroderma

92. Sjogren's Syndrome

93. Sticky Blood Syndrome

94. Still's Disease

95. Stiff Man Syndrome

96. Sydenham Chorea

97. Systemic Lupus Erythmatosis (SLE)

98. Takayasu's Arteritis

99. Temporal Arteritis

100. Ulcerative Colitis

101. Vasculitis

102. Vitiligo

103. Wegener's Granulomatosis

104. Wilson's Syndrome (Thyroid Disorder)

__________________________________________________________________________________________________________________________________

9


HYPOHYPOHYPOHYPOTHYROIDTHYROIDTHYROIDTHYROIDISISISISM SYMPTOM M SYMPTOM M SYMPTOM M SYMPTOM CHECKLISTCHECKLISTCHECKLISTCHECKLIST FOR DOCTOR CONSULTATIONFOR DOCTOR CONSULTATIONFOR DOCTOR CONSULTATIONFOR DOCTOR CONSULTATION

If you’re not sure if you have HYPO- or HYPERthyroidism, you can fill out both lists. Some symptoms are the same for each, but other symptoms are very specific to that condition.

If you already know you have HYPOthyroidism or Hashimoto’s Disease, this will be the list to complete. After completing the following questions and Symptom List, copy and give the copy to your practitioner in your consultation for their use and file.

1. Have you been diagnosed with hypothyroidism? Explain.

2. Have you been diagnosed with Hashimoto’s Disease? Explain.

3. Do you still have your full 2-sided thyroid? If not, explain (include year, why, where, etc.):

4. What thyroid medications, if any, are you taking? The kind/name? Dosage?

5. When did you start taking it?

__________________________________________________________________________________________________________________________________

10


HYPOHYPOHYPOHYPOTHYROIDTHYROIDTHYROIDTHYROIDISM ISM ISM ISM SymptomSymptomSymptomSymptom CheckCheckCheckCheckllllistististist

Mark 0Mark 0Mark 0Mark 0----10 for your pain or symptom level10 for your pain or symptom level10 for your pain or symptom level10 for your pain or symptom level and any notes that will help you doctor.and any notes that will help you doctor.and any notes that will help you doctor.and any notes that will help you doctor.

0 = no pain or 0 = no pain or 0 = no pain or 0 = no pain or symptoms to 10 symptoms to 10 symptoms to 10 symptoms to 10 = = = = extreme pain or full symptomsextreme pain or full symptomsextreme pain or full symptomsextreme pain or full symptoms ENERGY & SLEEPENERGY & SLEEPENERGY & SLEEPENERGY & SLEEP

1. Chronic fatigue and sluggishness

2. Lethargy

3. Excessive sleepiness

4. Waking up at night/can’t fall back to sleep

5. Decreased concentration/”Foggy” brain

6. Forgetfulness: Poor short-term memory and forgetfulness

7. Difficulty making decisions

STABILITY & STRESSSTABILITY & STRESSSTABILITY & STRESSSTABILITY & STRESS

8. Dizziness

9. Anxiety

10. Panic

11. Depression/apathy

12. Mood swings/crying unexpectedly

13. Feelings of worthlessness

14. Losing interest in normal daily activities

15. Suicidal thoughts

METABOLISM/BODYMETABOLISM/BODYMETABOLISM/BODYMETABOLISM/BODY

16. Increased sensitivity to cold/cold intolerance/chills

17. Cold hands and feet

__________________________________________________________________________________________________________________________________

11


18. Low body temperature

19. Constipation

20. Unexplained weight gain, most of which is fluid; difficulty losing weight

SKIN/HAIR/NAILSSKIN/HAIR/NAILSSKIN/HAIR/NAILSSKIN/HAIR/NAILS

21. Pale, dry skin

22. Thinning, dull hair

23. Dry, brittle, coarse hair

24. Premature graying of hair

25. Loss of eyebrows from outside in

26. Ridged, brittle/think fingernails

27. Fungal infection of nails

28. Slight rosiness/reddening of face

BODY CHANGESBODY CHANGESBODY CHANGESBODY CHANGES

29. Puffy face

30. Blurred vision

31. Gritty, burning dry eyes

32. Eyes sensitive to light

33. Eyes get jumpy/tics in eyes, which makes me dizzy/vertigo and have headaches

34. Swelled tongue -indentations on sides from teeth

35. Fungal infection of mouth

36. Dowagers Hump

37. Swelled feet, ankles, legs

38. Tinnitus (ringing in ears)

__________________________________________________________________________________________________________________________________

12


39. Vague aches and pains

40. Muscle aches, tenderness and stiffness, especially in shoulders and hips

41. Pain and stiffness in joints

42. Swelling of the legs / in knees or the small joints in hands and feet

43. Muscle weakness, especially in lower extremities

44. Tingling in lower legs / below knees

45. Recurrent sinus infections

46. Cramping of toes, stabbing feeling in pads of toes

47. Getting more frequent infections that last longer

48. Sagging eye lids

49. Hoarse voice/rough-deeper

50. Loose skin under upper arms

51. Loose skin under chin

52. Loose, sagging skin at midsection

53. Heart palpitations

54. Loss of libido, lack of sex drive

55. Feel the need to yawn to get oxygen

56. Bloody nose

57. Elevated blood cholesterol level

58. Strange feelings in neck or throat

HORMONALHORMONALHORMONALHORMONAL

59. Women: Heavier than normal periods / Excessive or prolonged menstrual bleeding (menorrhagia) and pain.

60. Women: Loss of menstrual cycle.

__________________________________________________________________________________________________________________________________

13


61. Women: Hot flashes

62. Women: Infertility/miscarriage

HYPOGLYCEMIA HYPOGLYCEMIA HYPOGLYCEMIA HYPOGLYCEMIA (Can be directly linked to hypothyroidism)

63. Crave sugary carbohydrates

64. Crave bread, pasta/sour dough bread/butter

65. Crave chocolate and sweets

66. Black outs due to sugar

67. Eyes get light spots /migraines

ADD ADD ADD ADD ANY YOU EXPERIENCE NOT LISTEDANY YOU EXPERIENCE NOT LISTEDANY YOU EXPERIENCE NOT LISTEDANY YOU EXPERIENCE NOT LISTED

__________________________________________________________________________________________________________________________________

14


HYPHYPHYPHYPERERERERTHYROIDTHYROIDTHYROIDTHYROIDISMISMISMISM SYMPTOM CHECKSYMPTOM CHECKSYMPTOM CHECKSYMPTOM CHECKLISTLISTLISTLIST FOR DOCTOR CONSULTATIONFOR DOCTOR CONSULTATIONFOR DOCTOR CONSULTATIONFOR DOCTOR CONSULTATION If you already know you have HYPERthyroidism or Graves’ Disease, this will be the list to complete. After completing the following questions and Symptom List, copy and give the copy to your practitioner in your consultation for their use and file.

1. Have you been diagnosed with hyperthyroidism? Explain.

2. Have you been diagnosed with Graves' Disease? Explain.

3. Have you been diagnosed with a Goiter? Explain.

4. Do you still have your full 2-sided thyroid? If not, explain (include year, why, where, etc.):

5. What thyroid medications, if any, are you taking? The kind/name? Dosage?

6. When did you start taking it?

__________________________________________________________________________________________________________________________________

15


HYPERHYPERHYPERHYPERTHYROIDTHYROIDTHYROIDTHYROIDISMISMISMISM Symptom CheckSymptom CheckSymptom CheckSymptom Checkllllistististist

Mark 0Mark 0Mark 0Mark 0----10 for your pain or symptom level 10 for your pain or symptom level 10 for your pain or symptom level 10 for your pain or symptom level and any notes that will help you doctor.and any notes that will help you doctor.and any notes that will help you doctor.and any notes that will help you doctor.

0 = no pain or 0 = no pain or 0 = no pain or 0 = no pain or symptoms to 10 = extreme pain or full symptomssymptoms to 10 = extreme pain or full symptomssymptoms to 10 = extreme pain or full symptomssymptoms to 10 = extreme pain or full symptoms ENERGY & SLEEPENERGY & SLEEPENERGY & SLEEPENERGY & SLEEP

1. Irritability

2. Insomnia: difficulty getting to sleep, staying asleep, or going back to sleep after awakening in the middle of the night


4. Feel fatigued, exhausted


5. Nervousness: a lot of nervous energy that I need to burn off

6. Irritable

7. Panic disorder

8. Moods change easily

9. Difficulty concentrating or focusing

10. Can't seem to remember things

11. Depressed

12. Vertigo

13. Some lightheadedness


14. Heat sensitivity: feeling inappropriately hot or overheated

15. Increased perspiration

16. Stomach upset

17. Diarrhea

__________________________________________________________________________________________________________________________________

16


18. Bowel movement frequently

19. Unexplained weight loss

20. Losing weight but my appetite has increased

21. Weight gain: hyperthyroidism can cause both weight loss and gain depending on balance of appetite changes vs metabolism changes


22. Warm skin

23. Skin: coarse, dry, scaly, thinning

24. Hair: coarse and dry, breaking, brittle

25. Fine hair

26. Thinning of hair

27. Hair is falling out


28. Goiter

29. Flushing

30. Eye/vision changes

31. Eyes feel sensitive to light

32. Eyes feel gritty and dry

33. Eyes seem to be enlarging, or getting more "bug-eyed" looking


35. Itchy skin

36. Rapid heartbeat, racing heart

__________________________________________________________________________________________________________________________________

17



38. Breathlessness: feel shortness of breath and tightness in the chest

39. Pulse is unusually fast

40. Hand tremors, shaky hands

41. Muscular weakness: especially involving the

upper arms and thighs

42. Weak leg muscles


44. Getting more frequent infections, that last longer



46. Women: Lighter than normal periods

47. Women: Decreased menstruation

48. Women: Period stops

49. Women: Miscarriages

50. Women: Hard time getting pregnant

51. Severe menstrual cramps

52. Women or men: No sex drive, or am having sexual performance problems

ADD ADD ADD ADD ANY YOU EXPERIENCE NOT LISTEDANY YOU EXPERIENCE NOT LISTEDANY YOU EXPERIENCE NOT LISTEDANY YOU EXPERIENCE NOT LISTED

__________________________________________________________________________________________________________________________________

18


FYBROMYALGIAFYBROMYALGIAFYBROMYALGIAFYBROMYALGIA Symptom ChecklSymptom ChecklSymptom ChecklSymptom Checklistististist


0 = no pain or 0 = no pain or 0 = no pain or 0 = no pain or symptoms to 10 = extreme pain or full symptomssymptoms to 10 = extreme pain or full symptomssymptoms to 10 = extreme pain or full symptomssymptoms to 10 = extreme pain or full symptoms ENERGY & SLEEPENERGY & SLEEPENERGY & SLEEPENERGY & SLEEP

1. Fatigue, unrefreshing sleep, waking up tired, morning stiffness

2. Insomnia, frequent waking, difficulty falling asleep, or falling asleep immediately

3. Anxiety, depression and "fibrofog"or “fog brain”:The term used to describe the confusion and forgetfulness, inability to concentrate and difficulty recalling simple words and numbers, and transposing words and numbers

4. Difficulty remembering, concentrating, and performing simple mental tasks



6. Moderate or severe fatigue and decreased energy

7. Balance problems

8. Neurally mediated hypotension: When you stand up, your blood pressure drops, which can make you feel faint, dizzy, nauseous, your heart rate drops, and you can even pass out

9. Dizziness

10. Tension or migraine headaches

11. Feeling anxious or depressed

__________________________________________________________________________________________________________________________________

19


BODYBODYBODYBODY----MUSCLESMUSCLESMUSCLESMUSCLES----PAINPAINPAINPAIN

12. Headaches, tenderness of the scalp, pain in the back of the skull

13. Jaw and facial tenderness

14. Feeling of pain, burning, aching, and soreness in the body

15. Chronic muscle pain, muscle spasms or tightness, weakness in the limbs, and leg cramps

16. Pain in the neck, shoulder, shoulder blades and elbows

17. Pain in hips, top of buttocks, outside the lower hip, below buttocks, and the pelvis

18. Pain in the knees and kneecap area

19. Reduced tolerance for exercise and muscle pain after exercise

20. Chest pain, palpitations

21. Restless leg syndrome

22. Muscle twitching

23. Numbness or tingling in the face, arms, hands, legs, or feet


24. Raynaud's phenomenon (where your hands feel cold, numb, or turn blue, when exposed to temperature changes)

25. Sense of tissues feeling swollen

26. Sensitivity to one or more of the following: odors, noise, bright lights, medications, certain foods, and cold

27. Shortness of breath

__________________________________________________________________________________________________________________________________

20


28. Abdominal pain, bloating, nausea, and constipation alternating with diarrhea (irritable bowel syndrome)


29. Irritable bowel syndrome, diarrhea and constipation, bloating, cramping

30. Numbness, tingling and feeling of cold in the hands and feet

31. Frequent urination

32. Dry mouth

33. Stiffness upon waking or after staying in one position for too long

34. Increase in urinary urgency or frequency (irritable bladder)


35. Women: Painful periods

ADD ANY YOU EXPERIENCE NOT LISTEDADD ANY YOU EXPERIENCE NOT LISTEDADD ANY YOU EXPERIENCE NOT LISTEDADD ANY YOU EXPERIENCE NOT LISTED

__________________________________________________________________________________________________________________________________

21


DOCTOR APPOINTMENT / SYMPTOM DOCTOR APPOINTMENT / SYMPTOM DOCTOR APPOINTMENT / SYMPTOM DOCTOR APPOINTMENT / SYMPTOM WEEKLY WEEKLY WEEKLY WEEKLY CHECKCHECKCHECKCHECKLISTLISTLISTLIST (An example: You don’t need to print.) The following is the list of symptoms with spaces to the right for each of your doctor appointments. Even if you don’t see your doctor weekly, it’s good to keep this documentation on a weekly basis so that you really see what’s changing or not and your doctor can treat you accordingly. FILL IN: The appointment dates at the top, including your weight (because, if you are going to be on the thyroid diet, you will most likely be losing

weight!) and then for each symptom mark 0 -10: 0 = no pain or symptoms to 10 = extreme pain or full symptoms. This way, you are keeping track of your symptoms getting better or worse with the treatment plan your doctor prescribes, giving him/her ongoing feedback to help regulate the changes necessary for your best outcome. I find it helpful to fill this in the night before my appointment. COPY IT: Make a copy of your first one filled in and give to the doctor for their chart. Then, every time you go in for an appointment, fill in their copy too and you’ll both be on the same page!

Here is an example sheetHere is an example sheetHere is an example sheetHere is an example sheet....

HYPOHYPOHYPOHYPOTHYROIDISMTHYROIDISMTHYROIDISMTHYROIDISM Symptom Symptom Symptom Symptom ChecklChecklChecklChecklistististist

10 / 28

Wk 1

/

/

/

/

/

/

/

/

/

/

/

/

/

WEIGHTWEIGHTWEIGHTWEIGHT 192

ENERGY & SLEEPENERGY & SLEEPENERGY & SLEEPENERGY & SLEEP


2. Lethargy







8. Dizziness

Date at top. Example: 10 (October) / 28 Under it is the number of the appointment or session (1 for the first one), keeping it easy to know how many appointments you’ve had. Some Drs have a set amount of appointments, so it’s easy to see and remember this way. I find it best to keep this up weekly, even when I don’t have an appointment. The future dates are left blank for you to pencil in before you get to the appointment —fill in the night before so you don’t forget and get rushed.

Write in each symptom box for that week before you go to see your doctor for that weeks or next appointment. If a symptom is gone (yea!) still put 0 or a line “-“ in the box. Hopefully, you’ll see the symptoms marked 10 going down to 0s in more and

more boxes as you move to the right of the list! The next pages are yours to use.

This list ends at 13 weeks.

Print out another and write in 14 where the “1” is on this one and

keep going.

__________________________________________________________________________________________________________________________________

22


HYPOHYPOHYPOHYPOTHYROIDTHYROIDTHYROIDTHYROIDISM ISM ISM ISM SymptomSymptomSymptomSymptom ChecklChecklChecklChecklistististist

/

1

/

/

/

/

/

/

/

/

/

/

/

/

WeightWeightWeightWeight



2. Lethargy







8. Dizziness

9. Anxiety

10. Panic

11. Depression/apathy

12. Mood swings/crying unexpectedly

13. Feelings of worthlessness

14. Losing interest in normal daily activities

15. Suicidal thoughts


16. Increased sensitivity to cold/cold intolerance/chills

17. Cold hands and feet

18. Low body temperature

19. Constipation

__________________________________________________________________________________________________________________________________

23


Write in week numbers here-->

20. Unexplained weight gain, most of which is fluid; difficulty losing weight


21. Pale, dry skin

22. Thinning, dull hair

23. Dry, brittle, coarse hair

24. Premature graying of hair

25. Loss of eyebrows from outside in

26. Ridged, brittle/think fingernails

27. Fungal infection of nails

28. Slight rosiness/reddening of face


29. Puffy face

30. Blurred vision

31. Gritty, burning dry eyes

32. Eyes sensitive to light


34. Swelled tongue -indentations on sides from teeth

35. Fungal infection of mouth

36. Dowagers Hump

37. Swelled feet, ankles, legs

38. Tinnitus (ringing in ears)

39. Vague aches and pains

40. Muscle aches, tenderness and stiffness, especially in shoulders and hips

41. Pain and stiffness in joints

42. Swelling of the legs / in knees or the small joints in hands and feet

__________________________________________________________________________________________________________________________________

24



43. Muscle weakness, especially in lower extremities

44. Tingling in lower legs / below knees


46. Cramping of toes, stabbing feeling in pads of toes

47. Getting more frequent infections that last longer

48. Sagging eye lids

49. Hoarse voice/rough-deeper

50. Loose skin under upper arms

51. Loose skin under chin

52. Loose, sagging skin at midsection


54. Loss of libido, lack of sex drive

55. Feel the need to yawn to get oxygen

56. Bloody nose

57. Elevated blood cholesterol level



59. Women: Heavier than normal periods / Excessive or prolonged menstrual bleeding (menorrhagia) and pain.

60. Women: Loss of menstrual cycle.

61. Women: Hot flashes

62. Women: Infertility/miscarriage

ADD ADD ADD ADD ANY YOU EXPERIENCE NOT ANY YOU EXPERIENCE NOT ANY YOU EXPERIENCE NOT ANY YOU EXPERIENCE NOT LISTEDLISTEDLISTEDLISTED

__________________________________________________________________________________________________________________________________

25


HYPERHYPERHYPERHYPERTHYROIDTHYROIDTHYROIDTHYROIDISMISMISMISM Symptom CheckSymptom CheckSymptom CheckSymptom Checkllllistististist

/

1

/

/

/

/

/

/

/

/

/

/

/

/

WeightWeightWeightWeight


1. Irritability

2. Insomnia: difficulty getting to sleep, staying asleep, or going back to sleep after awakening in the middle of the night


4. Feel fatigued, exhausted


5. Nervousness: a lot of nervous energy that I need to burn off

6. Irritable

7. Panic disorder

8. Moods change easily

9. Difficulty concentrating or focusing

10. Can't seem to remember things

11. Depressed

12. Vertigo

13. Some lightheadedness


14. Heat sensitivity: feeling inappropriately hot or overheated

15. Increased perspiration

16. Stomach upset

17. Diarrhea

__________________________________________________________________________________________________________________________________

26



18. Bowel movement frequently

19. Unexplained weight loss

20. Losing weight but my appetite has increased

21. Weight gain: hyperthyroidism can cause both weight loss and gain depending on balance of appetite changes vs metabolism changes


22. Warm skin

23. Skin: coarse, dry, scaly, thinning

24. Hair: coarse and dry, breaking, brittle

25. Fine hair

26. Thinning of hair

27. Hair is falling out


28. Goiter

29. Flushing

30. Eye/vision changes

31. Eyes feel sensitive to light

32. Eyes feel gritty and dry

33. Eyes seem to be enlarging, or getting more "bug-eyed" looking


35. Itchy skin

36. Rapid heartbeat, racing heart


38. Breathlessness: feel shortness of breath and tightness in the chest

__________________________________________________________________________________________________________________________________

27



39. Pulse is unusually fast

40. Hand tremors, shaky hands

41. Muscular weakness: especially

involving the upper arms and thighs

42. Weak leg muscles


44. Getting more frequent infections, that last longer



46. Women: Lighter than normal periods

47. Women: Decreased menstruation

48. Women: Period stops

49. Women: Miscarriages

50. Women: Hard time getting pregnant

51. Severe menstrual cramps

52. Women or men: No sex drive, or am having sexual performance problems

ADD ANY YOU EXPERIENCE NOT ADD ANY YOU EXPERIENCE NOT ADD ANY YOU EXPERIENCE NOT ADD ANY YOU EXPERIENCE NOT LISTEDLISTEDLISTEDLISTED

__________________________________________________________________________________________________________________________________

28


FOOD & EATING DOCUMENTATION (FFOOD & EATING DOCUMENTATION (FFOOD & EATING DOCUMENTATION (FFOOD & EATING DOCUMENTATION (F....EEEE....DDDD....) ) ) ) ---- LogLogLogLog in a spiral notebookin a spiral notebookin a spiral notebookin a spiral notebook Use to write in as you eat and for preplanning your menu.Use to write in as you eat and for preplanning your menu.Use to write in as you eat and for preplanning your menu.Use to write in as you eat and for preplanning your menu.

Day/Date Time awake / Line down the middle of the page.Line down the middle of the page.Line down the middle of the page.Line down the middle of the page. Time actually up for day I do the same on this side of the notebook page. Two to a page.

The next day I flip the page, and on the back do it all again! 9 a.m. Green Smoothie: 2-3 cups of spinach Protein powder Almond milk Banana Flaxseeds

11:30 Hot herbal tea Rice crackers Almond butter 1:30 Ate at China Buffet (YUM!) Shrimp: Grilled and boiled Grilled chicken on a stick Veggies

Bacon wrapped crab Honeydew / Watermelon Lemon water 6:00 Baked chicken breast P Bed of spinach V

Carrots V Onions V Flaxseeds Fb/O Butter O 9:00 Cantaloupe

Almonds

Bottom of page: Ex: (for exercise) Mel: Y/N (for if I took Melatonine)

Note what I did. Bed: (Time went to bed) BM: 0 1 2 3 (Bowel Movement, circle one or just put #)

TIME: The reason I have the time/time is because one of the symptoms of thyroid problems is not being able to sleep, plus, the first one is usually to go to the bathroom! If I stay awake and can’t go back to sleep, I note that too.

I don’t write “breakfast/lunch/dinner,” I just mark the times I eat and what I eat. You certainly can however if it helps you keep or create a healthy eating pattern.

It can also be helpful to put initials next to each food to check and see if you’re getting a balance of fruit, vegetables, protein, etc in for the day. P — Protein M — Meat Fs — Fish N — Nuts L — Legumes (Protein and Fiber) F — Fruit V — Vegetable Fb- Fiber O — Oil

Bowel Movement (BM) Okay, who likes to talk about this! However, one of the nasty symptoms of thyroid disease is constipation. So, when my doctor had me take a “stool sample”* lab test (it’s a good thing!) I noticed that the lab paperwork showed three little illustrations of what should identify one’s poo. Use 0-3 to identify your BM activity. #0: No BM at all; might feel bloated and like you have

to go, but it won’t come out. #1: constipation poo: separate globs that look like

rabbit pellets, roundish balls that are hard to release and can take a while. I hate these!!

#2: a better/healthier poo: softer and smoother but still

had some round rabbit pellets in it. #3: “Normal” healthy poo: softish and, as Dr. Oz says

on Oprah, “Has that little swirl at the end like ice cream from a machine!” And, this would move smoothly and right out of you without pushing or working at it. That’s where we want to be!

*STOOL SAMPLE: Numerous things can affect our immune system in a way that impacts blood sugar and digestion–causing bloating–these include parasites, pathogens, infections and heavy metal and chemical toxicities. A stool sample, saliva tests and other lab tests can help detect these to then eliminate them.

__________________________________________________________________________________________________________________________________

29


Date:

Date:

Date:

Breakfast

Breakfast

Breakfast

Snack

Snack

Snack

Lunch

Lunch

Lunch

Snack

Snack

Snack

Dinner

Dinner

Dinner

Snack Water

Snack Water

Snack Water

Water: G G G G G G G G G

Vegetables________

Fruits________ Protein: Meat/Fish________

Milk Substitute: Almond Milk/Rice/Other________ Fat/Oils________ Fiber________


Vegetables________


Milk Substitute: Almond Milk/Rice/Other________ Fat/Oils________

Fiber________


Vegetables________


Milk Substitute: Almond Milk/Rice/Other________ Fat/Oils________

Fiber________

__________________________________________________________________________________________________________________________________

30


HYPOGLYCEMIAHYPOGLYCEMIAHYPOGLYCEMIAHYPOGLYCEMIA Symptom CheckSymptom CheckSymptom CheckSymptom Checkllllistististist


0 = no pain or 0 = no pain or 0 = no pain or 0 = no pain or symptoms to 10 = symptoms to 10 = symptoms to 10 = symptoms to 10 = extreme pain or full symptomsextreme pain or full symptomsextreme pain or full symptomsextreme pain or full symptoms 1. Craving sweets and simple carbohydrates

2. Constant hunger, even right after a meal

3. Irritability if meals are missed

4. Become lightheaded if meals are missed

5. Dependency on coffee for energy

6. Eating to relieve fatigue

7. Feeling shaky, jittery or tremulous (tremors)

8. Unexplained tiredness/Exhaustion

9. Gasping for breath

10. Smothering spell

11. Feeling agitated and nervous


13. Sighing and yawning

14. Constant worrying

15. Depression

16. Sweating and/or cold sweats

17. Skin conditions

__________________________________________________________________________________________________________________________________

31


18. Becoming upset easily: Outbursts of anger, feeling out of control emotionally

19. Unsocial, asocial, or antisocial behavior

20. Phobias

21. Fears

22. Confusion, abnormal behavior or both, such as the inability to complete routine tasks

23. Suicidal impulses

24. Nervous breakdowns

25. Lack of sex drive/libido

26. MALES: Impotency

27. Feeling weepy, crying for no reason, or more emotionally sensitive to everything

28. Light-headed, dizziness, faintness

29. Literally saying a different word in a sentence than you were going to say

30. Lack of coordination

31. Staggering

32. Fog-brain, poor memory, forgetfulness

33. Blackouts — can’t remember that you did something though were completely awake and doing it. (Blackout are usually attributed to alcoholism.)

34. Seizures, though uncommon

35. Convulsions

36. Vertigo

__________________________________________________________________________________________________________________________________

32


37. Night terrors

38. Numbness

39. Muscle pain

40. Twitching and jerking muscles

41. Muscle cramps

42. Arthritis

43. Asthma / Allergies

44. Loss of consciousness, though uncommon

45. Visual disturbances, such as double vision and blurred vision

46. Headaches, migraines when sugar, simple carbohydrates are eaten

47. Itching and crawling sensations on the skin; like little pin pricks or bites

48. Obesity

49. Death (just to let you know how serious this is!)

Other:

50.

51.

52.

53.

54.

55.

56.

__________________________________________________________________________________________________________________________________

33


HIGH BLOOD SUGAR /HIGH BLOOD SUGAR /HIGH BLOOD SUGAR /HIGH BLOOD SUGAR / INSULIN RESISTANCEINSULIN RESISTANCEINSULIN RESISTANCEINSULIN RESISTANCE Symptom CheckSymptom CheckSymptom CheckSymptom Checkllllistististist


0000 = no pain or = no pain or = no pain or = no pain or symptoms to 10 = extreme pain or full symptomssymptoms to 10 = extreme pain or full symptomssymptoms to 10 = extreme pain or full symptomssymptoms to 10 = extreme pain or full symptoms 1. Fatigue after meals / General fatigue

2. Craving for sweets that is not relieved by eating them / Must have sweets after meals

3. Waist girth is equal or larger than hip girth

4. Frequent urination

5. Increased appetite and thirst

6. Difficulty losing weight

7. Migrating aches and pains

8. Becoming upset easily: Outbursts of anger, feeling out of control emotionally

9. Confusion, abnormal behavior or both, such as the inability to complete routine tasks

10. Feeling weepy, crying for no reason, or more emotionally sensitive to everything

11. Light-headed

12. Literally saying a different word in a sentence than you were going to say

13. Fog-brain, poor memory, forgetfulness

14. Blackouts — can’t remember that you did something though were completely awake and doing it. (Blackout are usually attributed to alcoholism.)

15. Loss of consciousness, though uncommon

16. Visual disturbances, such as double vision and blurred vision

__________________________________________________________________________________________________________________________________

34


WHEN TO TAKE MEDICATIONSWHEN TO TAKE MEDICATIONSWHEN TO TAKE MEDICATIONSWHEN TO TAKE MEDICATIONS & SUPPLEMENTS& SUPPLEMENTS& SUPPLEMENTS& SUPPLEMENTS (An example: You do not need to print.) Your doctor will instruct you when to take your medications and supplements. It can feel constricting and overwhelming some days when you have a lot to take and keep track of, but it’s not forever. And, if it is forever . . . a list of some sort to check dosages taken will be very important and helpful.

Consistency is the key. I’m a late night person so my times can vary a bit depending on when I get to bed and then up in the morning, but I try to keep these as consistent as possible so that they are working in my body consistently for me. WORK and TRAVEL: If you’re traveling or just going to be out for more than a couple of hours or at work all day, plan ahead to take your pill/supplement supply with you and foods that you can eat. Fill it out once and make copies and you’re set to go!

Daily Medication Daily Medication Daily Medication Daily Medication and Supplement and Supplement and Supplement and Supplement

CheckCheckCheckCheckllllistististist Day:

AM AM AM AM PM PM PM PM

Med Name or just initials that you know what they are

5

Med Name

In-between pill box 7

Big pill box 9


Big pill box 3


Big pill box 9

Medicated Cream A Name

7

Medicated Cream B Name

7 2 9

Medicated Cream C Name

2 9

Drops A 7 6

Drops B 7 2 9

Drops C

Drops D

__________________________________________________________________________________________________________________________________

35


Daily Medication Daily Medication Daily Medication Daily Medication and Supplement and Supplement and Supplement and Supplement

ChecklChecklChecklChecklistististist

Day:

AM AM AM AM PM PM PM PM Daily Medication Daily Medication Daily Medication Daily Medication and Supplement and Supplement and Supplement and Supplement

CheckCheckCheckCheckllllistististist

Day:

AM AM AM AM PM PM PM PM

__________________________________________________________________________________________________________________________________

36


WATER LOGWATER LOGWATER LOGWATER LOG Choice: Water, Choice: Water, Choice: Water, Choice: Water, herbal teaherbal teaherbal teaherbal tea

Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date

Using the formula:Using the formula:Using the formula:Using the formula: Weight: __________, divided by 2 =______ divided by 8 =______ ounces per day: ____oz

1 x 8 ounces = 1 cup

2 x 8

3 x 8

4 x 8 1 Quart

5 x 8

6 x 8

7 x 8

8 x 8 ½ Gallon

9 x 8

10 x 8

11 x 8

12 x 8 ¾ Gallon

13 x 8

14 x 8

15 x 8

16 x 8 1 Gallon

__________________________________________________________________________________________________________________________________

37


EXERCISE PLANEXERCISE PLANEXERCISE PLANEXERCISE PLAN Date:

TimeTimeTimeTime Kind of ExerciseKind of ExerciseKind of ExerciseKind of Exercise //// DistanceDistanceDistanceDistance


How I feel today 0 (no symptoms) — 10 (extreme pain in joints, body aches)

Monday, Wednesdays and Fridays

7 a.m.

Walk 1.5 miles (treadmill when busy)

5:30 p.m.

Arm weights, 3 exercises, 12 reps each

Tuesday, Thursday and Saturdays

7 a.m. Stationary bicycle 1.5 miles

5:30 p.m.

Arm weight, 3 exercises, 12 reps each and extra stretching

Sunday No later than 6 p.m.

Preplan beginning of week: Go for a hike with a friend, walk around the block, get outside

__________________________________________________________________________________________________________________________________

38


EXERCISE LOGEXERCISE LOGEXERCISE LOGEXERCISE LOG (Twice/day) Date:



How I feel today 0 (no symptoms) — 10 (extreme pain in joints, body aches)

__________________________________________________________________________________________________________________________________

39


PRACTITIONER PRACTITIONER PRACTITIONER PRACTITIONER APPOINTMENT APPOINTMENT APPOINTMENT APPOINTMENT LOGLOGLOGLOG: : : : Date/Time

Name of PractitionerName of PractitionerName of PractitionerName of Practitioner Reason for AppointmentReason for AppointmentReason for AppointmentReason for Appointment Prescribed TreatmentPrescribed TreatmentPrescribed TreatmentPrescribed Treatment: : : : Medications / Medications / Medications / Medications / Supplements / Etc.Supplements / Etc.Supplements / Etc.Supplements / Etc.

__________________________________________________________________________________________________________________________________

40


MASTER MASTER MASTER MASTER PRACTITIONER PRACTITIONER PRACTITIONER PRACTITIONER APPOINTMENT APPOINTMENT APPOINTMENT APPOINTMENT LOG: LOG: LOG: LOG: Date

Name of PractitionerName of PractitionerName of PractitionerName of Practitioner MASTER MASTER MASTER MASTER PRACTITIONER PRACTITIONER PRACTITIONER PRACTITIONER APPOINTMENT APPOINTMENT APPOINTMENT APPOINTMENT LOG: LOG: LOG: LOG: Date

Name of PractitionerName of PractitionerName of PractitionerName of Practitioner

__________________________________________________________________________________________________________________________________

41


LAB LAB LAB LAB TESTSTESTSTESTSTESTS LOGLOGLOGLOG Document everything. Print more sheets as needed.

Date Date Date Date PractitionerPractitionerPractitionerPractitioner PurposePurposePurposePurpose: What tests?: What tests?: What tests?: What tests? Insurance SentInsurance SentInsurance SentInsurance Sent Paid? Outcome. Follow upPaid? Outcome. Follow upPaid? Outcome. Follow upPaid? Outcome. Follow up

__________________________________________________________________________________________________________________________________

42


INSURANCE COMPANY / BILLINGS LOGINSURANCE COMPANY / BILLINGS LOGINSURANCE COMPANY / BILLINGS LOGINSURANCE COMPANY / BILLINGS LOG ———— OVERALL DOCUMENTATIONOVERALL DOCUMENTATIONOVERALL DOCUMENTATIONOVERALL DOCUMENTATION Document everything. Print more sheets as needed.

Date Date Date Date PractitionerPractitionerPractitionerPractitioner PurposePurposePurposePurpose Insurance SentInsurance SentInsurance SentInsurance Sent Paid? Outcome. Follow upPaid? Outcome. Follow upPaid? Outcome. Follow upPaid? Outcome. Follow up

Documents

Get Your Life Back!Get Your Life Back! - thyroidu.comthyroidu.com/wp-content/uploads/2012/04/Get-Your-Life-Back-Thyroid...1 ©2011 Kim Wolinski, MSW “Dr. DeClutter” Get Your Life