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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
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 / 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
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.
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
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?
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
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?
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
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. Fatigue, unrefreshing sleep, waking up tired, morning stiffness
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
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....
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
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.
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 = 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
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.
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
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
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
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
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.
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
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
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