Date of Interview:

Serial No.

Questionnaire
Instructions: Please attempt all questions. Mark a tick or fill in the blanks as appropriate.
Q1. Name: ______________________ Q2. Age: ______ (in years) Q4. Marital Status: 1) Single 2) Married 3) Other Q3. Sex: 1) Male 2) Female

Q5. Place of Residence: __________ Q8. Ethnicity: __________ 4) Illiterate

Q6. Religion: _________

Q7. Mother Tongue: __________ 2) Secondary

Q9. Education: 1) Primary

3) Intermediate

5) Other _____________________________ Q10. Employment status 1) Fulltime/Part-time 2) Unemployed 3) Retired 4) Homemaker Q11. Weight in kg _________ Q12. Height in feet _________

Q13. Physical complaints 1) Slow movements 2) Wt increase 3) Cold skin 4) Parasthesia 5) Periorbital puffiness 6) tolerating heat or cold 7) Diminished sweating 8) Increased sweating 9) Coarse skin 10) Constipation 11) Hearing impairment 12) Hair changes 13) change in voice 4) Any Other Please specify _____________________________ Q14. Any addictive substance use 1) Smoking 2) Paan with tobacco 3) Alcohol 4) Others Please specify _____________________________ Q.15 Take medicine to sleep: 1) Yes 2) No Q.16 I wake up early in the morning and I find it hard to get back to sleep: 1) Yes 2) No Q.17 I stay up much of the night: 1) Yes 2) No Q.18 I put a lot of time getting to sleep: 1) Yes 2) No Q.19 I sleep well at night: 1) Yes 2) No Q20: T3: ________pg/ml Q21: T4: ________pg/ml Q22:TSH: ________U/l Q23: HTG : ________ng/ml

Q24: Diagnosis : _____________________ Q25: Since how long you have been diagnosed: _____________________ Q26 Surgery done for the existing problem: 1) Yes 2) No If yes when it is done _______ (year) Q27: Histopathology finding (If present) : _____________________ (Type)