Session Info

Date:

Visit type:

Initial

Follow-up

Telehealth

Duration (min):

CPT / billing code:

Thyroid Assessment

Assess thyroid symptoms: fatigue, cold intolerance, constipation, hair/skin changes, weight change.

Assess secondary symptoms: mood shifts, memory/concentration, cycle/fertility, palpitations, tremor, and neck symptoms.

Verify thyroid medication timing (e.g. empty stomach 30-60m before breakfast, away from calcium/iron).

Assess key thyroid nutrient cofactors (iodine, selenium, zinc exposure).

Review comprehensive thyroid panel: TSH, Free T4, Free T3, and Reverse T3.

Review thyroid autoantibodies: TPO and Thyroglobulin antibodies.

Review metabolic and nutrient markers: CBC, CMP, Ferritin, Vitamin D, and Vitamin B12.

Fatigue, Stress & Hormone Screen

Scoring version

Corrected 2021

General fatigue: —
Physical fatigue: —
Reduced activity: —
Reduced motivation: —
Mental fatigue: —

General fatigue

1. I feel fit

Yes, that is true (1) Mostly true (2) Neutral (3) Mostly not true (4) No, that is not true (5)

5. I feel tired

Yes, that is true (1) Mostly true (2) Neutral (3) Mostly not true (4) No, that is not true (5)

12. I am rested

Yes, that is true (1) Mostly true (2) Neutral (3) Mostly not true (4) No, that is not true (5)

16. I tire easily

Yes, that is true (1) Mostly true (2) Neutral (3) Mostly not true (4) No, that is not true (5)

Physical fatigue

2. Physically I feel only able to do a little

Yes, that is true (1) Mostly true (2) Neutral (3) Mostly not true (4) No, that is not true (5)

8. Physically I can take on a lot

Yes, that is true (1) Mostly true (2) Neutral (3) Mostly not true (4) No, that is not true (5)

14. Physically I feel I am in a bad condition

Yes, that is true (1) Mostly true (2) Neutral (3) Mostly not true (4) No, that is not true (5)

20. Physically I feel I am in an excellent condition

Yes, that is true (1) Mostly true (2) Neutral (3) Mostly not true (4) No, that is not true (5)

Reduced activity

3. I feel very active

Yes, that is true (1) Mostly true (2) Neutral (3) Mostly not true (4) No, that is not true (5)

6. I think I do a lot in a day

Yes, that is true (1) Mostly true (2) Neutral (3) Mostly not true (4) No, that is not true (5)

10. I think I do very little in a day

Yes, that is true (1) Mostly true (2) Neutral (3) Mostly not true (4) No, that is not true (5)

17. I get little done

Yes, that is true (1) Mostly true (2) Neutral (3) Mostly not true (4) No, that is not true (5)

Reduced motivation

4. I feel like doing all sorts of nice things

Yes, that is true (1) Mostly true (2) Neutral (3) Mostly not true (4) No, that is not true (5)

9. I dread having to do things

Yes, that is true (1) Mostly true (2) Neutral (3) Mostly not true (4) No, that is not true (5)

15. I have a lot of plans

Yes, that is true (1) Mostly true (2) Neutral (3) Mostly not true (4) No, that is not true (5)

18. I don't feel like doing anything

Yes, that is true (1) Mostly true (2) Neutral (3) Mostly not true (4) No, that is not true (5)

Mental fatigue

7. When I am doing something, I can keep my thoughts on it

Yes, that is true (1) Mostly true (2) Neutral (3) Mostly not true (4) No, that is not true (5)

11. I can concentrate well

Yes, that is true (1) Mostly true (2) Neutral (3) Mostly not true (4) No, that is not true (5)

13. It takes a lot of effort to concentrate on things

Yes, that is true (1) Mostly true (2) Neutral (3) Mostly not true (4) No, that is not true (5)

19. My thoughts easily wander

Yes, that is true (1) Mostly true (2) Neutral (3) Mostly not true (4) No, that is not true (5)

Notes

Additional clinical observations...

Framework

Modern cortisol rhythm

Modern Stage

Select Modern Pattern

CAR Pattern (Cortisol Awakening Response)

Select CAR

Diurnal Slope

Select Slope

Free Cortisol (24hr Zone)

Select Zone

Metabolized to Free Cortisol Ratio

Select Ratio

Cortisol Phase Shift

Select Shift

Sample Collection Method

Select Method

Intervention Phase

Select Intervention Phase

Notes

Menopause context

Unknown Premenopause Perimenopause Postmenopause Surgical menopause

Responses

1. Hot flushes or sweating

None Mild Moderate Marked Severe

2. Heart discomfort

None Mild Moderate Marked Severe

3. Sleep problems

None Mild Moderate Marked Severe

4. Depressive mood

None Mild Moderate Marked Severe

5. Irritability

None Mild Moderate Marked Severe

6. Anxiety

None Mild Moderate Marked Severe

7. Physical and mental exhaustion

None Mild Moderate Marked Severe

8. Sexual problems

None Mild Moderate Marked Severe

9. Bladder problems

None Mild Moderate Marked Severe

10. Dryness of vagina

None Mild Moderate Marked Severe

11. Joint and muscular discomfort

None Mild Moderate Marked Severe

Notes

Menopause symptom notes and management...

Plan

Diagnosis Search

Working diagnosis / clinical impression

Coding Details

Status

Select status...

Severity

Select severity...

Onset Date

YYYY-MM-DD

Resolved Date

YYYY-MM-DD

Thyroid Marker Review

TSH:

Free T4:

Free T3:

Reverse T3:

TPO antibody:

Thyroglobulin antibody:

Ferritin:

Vitamin D 25-OH:

Vitamin B12:

Report details

Panel Kind

Blood

Vendor / Lab

e.g. Lifelabs, Dynacare

Panel Name

e.g. CBC, Lipid Panel

Collection Date

YYYY-MM-DD

Result Date

YYYY-MM-DD

Specimen Type

Search specimen...

Panel Status

Final

Source Document

No source document attached

Tests

Tests List Add test

No tests entered yet. Add a test to capture a value and reference interval.

Medications Add Medication

New Medication

Drug Name

e.g. Amoxicillin

Drug Code

RxNorm code...

Strength

e.g. 500 mg

Route

Select...

Frequency

Select...

Start Date

YYYY-MM-DD

Stop Date

YYYY-MM-DD

Notes

Notes / instructions...

Test Method

Select Method

Cycle Day

1-60

optional

Linked Lab Results

No linked lab results.

Estrogen Dominance

—

Progesterone Deficiency

—

Estrogen Deficiency

—

Androgen Excess

—

Androgen Deficiency

—

Cortisol Excess

—

Cortisol Deficiency

—

Hypothyroid Pattern

—

Hyperthyroid Pattern

—

Marker Snapshots + Add Marker

No marker snapshots recorded.

Notes

Rx formulation (levothyroxine / liothyronine / desiccated / compounded T4+T3):

Supplement considerations (selenium / iodine / iron / B12 / vitamin D):

Follow-Up

Problem / baseline:

Goal:

Interventions:

Review date:

Revision / discharge criteria:

Plan and Follow-Up

Plan area	Details
Next visit
Orders & referrals
Patient instructions
Monitoring & safety

Session Info

Thyroid Assessment

Fatigue, Stress & Hormone Screen

MFI-20

HPA Stage Assessment

Staging Framework

Cortisol Pattern

Plan

Notes

MRS

Plan

Diagnosis Snapshot

Thyroid Marker Review

Lab Result

Medication List

ND Hormone Pattern

Test Context

Identified Patterns

Markers & Observations

Notes

Follow-Up

Plan and Follow-Up

ND - Hypothyroidism Template

Preview