Gender:

Male
Female

Age:

Under 25  
26-34
35-44
45-54
55-64
65-74
75+

Race: 

White (Not Hispanic) 
African-American 
Asian/Pacific Islander 
Hispanic
Native American 
Other

Do you have a family history of thyroid problems?

Yes
No

Are you pregnant or have you given birth in the last six months?

Yes
No

Have you been exposed to a large amount of radiation?

Yes
No

Are you a smoker?

Yes
No

Are you taking medications with high levels of iodine?

Yes
No

Do you have trouble concentrating?

Yes
No

Are you always tired or exhausted?

Yes
No

Are you experiencing unexpected changes in your weight?

Yes
No

Are you depressed?

Yes
No

Do you have dry skin and brittle nails?

Yes
No