Changing Thyroid Medications - A Questionnaire for Patients

Physicians may recommend changes in thyroid hormone prescriptions for their patients. TFA is trying to gather information on patients’ experiences with such changes. Therefore, if you have been asked to change your thyroid hormone preparation we would appreciate your answering the following questionnaire which can be submitted online to TFA or you may print the Questionnaire and mail it at your convenience.

Please answer the following questions:
I changed my thyroid hormone prescription on	(date)
I was asked to change my prescription by my (check all that apply)	Doctor	Nurse
	Pharmacist	Other
Reason for changing medication (check all that apply)	Cost
	Insurance company requirement
	Other
What was the brand of medication before the change?
What brand were you switched to?
Follow-up thyroid testing result (please check one):	TSH higher (hypothyroidism)
	TSH lower (hyperthyroidism)
Symptomatic results on new treatment (please check one)	Felt better	(explain)
	Felt worse	(explain)
Overall satisfaction with medication change (please check one)	satisfied/improved
	satisfied/no change in how I feel
	unsatisfied
If unsatisfied with the medication change please give reasons
Privacy Statement

Preliminary results of this survey will be available in the next TFA newsletter. In addition we will have a discussion of the survey results on TFA’s home page on the Internet as soon as we have a significant number of responses.

Thank you for your help.

Sincerely,
Lawrence C. Wood, M.D.
Medical Director