Prevalence of abnormal thyroid function test in adults attending primary care setting in the year 2022 in the Kingdom of Bahrain

ABSTRACT

Background:

Thyroid disease is known to be one of the most common endocrine diseases globally and has serious health implications if left untreated.

Objective:

This study aimed to gain a better understanding of common thyroid diseases and to explore the associated risk factors in the Kingdom of Bahrain.

Methods:

A case-control study was carried out after obtaining all thyroid stimulating hormone (TSH) results done in a primary healthcare setting from January 1, 2022 to December 31, 2022 from the Health Information Department. In total, 500 participants were randomly selected from each group: the abnormal thyroid test group (cases) and the normal thyroid test group (controls). Participants were interviewed using a structured list of associated risk factors with the following sections: sociodemographic characteristics, comorbidities, family history of thyroid disease, BMI, previous radiation therapy, and certain medications.

Results:

The prevalence of abnormal thyroid tests was found to be 11%. Cases were categorized into four groups: hyperthyroidism (26.4%), hypothyroidism (64.6%), hyperthyroidism (4.5%), and subclinical hypothyroidism 13 (4.5%). The results showed significant differences between case and control in the following risk factors: female sex, increasing age, BMI, dyslipidemia, family history of thyroid disease, and previous radiation therapy (P = <0.05).

Conclusion:

In summary, the high prevalence of abnormal thyroid results highlights the need for an organized national screening program for individuals at average risk for developing thyroid disease.

Introduction

Thyroid disease is considered one of the prevailing endocrine diseases worldwide.[1] It includes hyperthyroidism and hypothyroidism. Both can occur as overt or subclinical.[2] It is vital to identify thyroid disease to prevent adverse consequences associated with it if left untreated.[3,4,5]

It has been reported that thyroid disease is associated with a number of medical conditions, including cardiovascular disease, dyslipidemia, infertility, and orbitopathy.[3,4,5] In addition, it has been found to have a negative impact on mental health and quality of life.[3,4,5]

It has been noted that the prevalence of overt hyperthyroidism ranges from 0.2% to 1.3% in iodine-sufficient parts of the world.[6] Contrarily, overt hypothyroidism is more common than overt hyperthyroidism globally with a prevalence of 0.2%–5.3%.[6,7] Remarkably, subclinical hypothyroidism is documented to have an even higher prevalence of 3%–15%.[8] Furthermore, the risk of progression from subclinical hypothyroidism to overt hypothyroidism is estimated to be around 4.3%–8%.[9]

Regionally, a number of studies were conducted in Saudi Arabia, which estimated the prevalence of overt hypothyroidism, subclinical hypothyroidism, and subclinical hyperthyroid to be around 18%,[10] 10.3%, and 2.1%,[9] respectively.

In Bahrain, a study done at the Royal Services of Bahrain Defense Force Military Hospital in 2020 showed that hypothyroidism is the most common thyroid disease among the Bahraini population, with a prevalence of 20%, followed by subclinical hypothyroidism (6.5%) and hyperthyroidism (3.3%).[11]

Thyroid disease is linked to a number of risk factors, including age, sex, weight, comorbidities, medications, previous radiation therapy, social factors (including smoking and alcohol consumption), and family history of thyroid disease.[2,3,9,12,13,14,15,16,17,18,19,20,21,22,23,24]

The aim of this study was to gain a better understanding of how common thyroid disorders are in primary care settings in the year 2022 in the Kingdom of Bahrain. The primary outcome was to determine the prevalence of thyroid disorders. The secondary outcome was to explore the associated risk factors of thyroid disorders.

Methodology

Study setting and design

This was a case–control study carried out on adults who had undergone thyroid stimulating hormone (TSH) test in the primary healthcare setting in the Kingdom of Bahrain from January 1, 2022 to December 31, 2022. The first step of selecting the sample was to retrieve all TSH results, both normal and abnormal, that were done during the study period. This sample was obtained from the Health Information Department (HID) by accessing the electronic filing system of the patients after obtaining ethical approval from the ethical committee. Data collection was carried out in May 2023.

Second, the participants were segregated into two groups, one containing all normal TSH tests and the other including all abnormal TSH tests. Then, 500 participants from each group were randomly selected using the Excel software. The general inclusion criteria were adults aged 18 years and above, speaking Arabic or English. The case group’s specific inclusion criteria were a TSH of <0.25 mIU/L, which indicates hyperthyroidism, or TSH >5 mIU/L, which indicates hypothyroidism. The control group’s specific was a TSH range of 0.25–5 mIU/L, which indicates normal thyroid function.

Before taking the random sample, we excluded patients less than 18 years of age, patients with no contact numbers, unreported TSH results, and duplicates. However, we had to exclude pregnancy, mental illness, critically ill patients, and language barrier after taking the random sample and contacting the patients because HID was unable to provide detailed information regarding each patient. In addition, those with single abnormal readings with unconfirmed thyroid disease or patients who were diagnosed with tumors or underwent thyroidectomy due to other reasons (other than hyperthyroid, including benign thyroid lesion and goiter) were also excluded.

Finally, informed verbal consent was obtained, and participants were interviewed through a phone call using a structured list of associated risk factors. The list included the following sections: sociodemographic characteristics (age, sex, smoking, alcohol), comorbidities (HTN, DM, dyslipidemia, SLE, RA, psoriasis, celiac disease, IBD, MS), family history of thyroid disease, weight/height (BMI), previous radiation therapy, and medications (antithyroid drugs, thyroxine, amiodarone, steroids, lithium) [Appendix 1].

Study population and sample size estimation

Based on the total number of TSH done in the period January 1, 2022 to December 31, 2022, we extrapolated two samples of 500 participants from normal and abnormal TSH groups by using an online sample size calculator, with a margin of error of 5%, confidence interval of 95%, and response proportion of 50%.[25] Based on the selected sample, the patients were interviewed accordingly during the study period.

Data collection tool and data collection procedure

Patients’ demographics, thyroid function test results, and thyroid medications were obtained from electronic medical records, and other risk factors for thyroid diseases were obtained from patients using telemedicine.

Upon contacting the selected patients, verbal consent was obtained, after which the interview was started using a structured list of risk factors where an association was studied in relation to thyroid disease in previous studies.[2,3,9,12,13,14,15,16,17,18,19,20,21,22,23,24]

The tool that was used is attached

An initial pilot study was conducted by interviewing 10 individuals to evaluate the data collection tool. The study took place during the month of September 2022. Individuals were asked each question in the tool, and their understanding was comprehended.

Data processing and analysis

The results were compiled and recorded into an Excel spreadsheet. The collected data was imported to SPSS version 26, where all variables were labeled and frequency checks for each variable were performed to see if there were any discrepancies. Frequencies and percentages were computed for categorical variables, while means and standard deviations were computed for continuous variables. The Chi-square test was used to compare two proportions, while the t-test was used to compare means between two independent groups. Eta squared was measured for independent samples t-test. Cramer’s V was measured for the Chi-square test. Binary logistic regression was used to explore the risk factors that were found to have an impact on thyroid disease. A P value of less than 0.05 was considered statistically significant.

Results

The total number of TSH tests provided by the Health Information Directory was 159,811, and the total number of abnormal TSH tests was 18,429. Hence, the prevalence of abnormal thyroid tests that were done in the year 2022 was 11.5%. The study included two samples: case and control. Out of the 500 cases, there were a total of 288 (57.6%) participants that fit the case definition, while 234 (46.8%) participants out of the 500 controls met the definition of controls [Figure 1].

Figure 1.

Sample selection process of study participants

The cases were categorized into four groups: hyperthyroidism (26.4%), hypothyroidism (64.6%), subclinical hyperthyroidism (4.5%), and subclinical hypothyroidism (4.5%) [Figure 2].

Figure 2.

Demonstration of diagnosis among case participants

An independent-sample t-test was conducted to compare the mean age and BMI between cases and controls. There was a significant difference for age (P = 0.001); where the mean age for cases was 48.79 (SD = 15.54) and for controls was 44.0 (SD = 15.76). The magnitude of the difference in the means = 4.78 (95% CI: 2.08–7.50) with a small difference (eta squared: 0.02). There was no significant difference in BMI between cases and controls. The cases’ mean BMI was 29.05 (SD = 6.59), whereas the controls’ mean BMI was 27.66 (SD = 6.31). The magnitude of the differences in the means was small (mean difference = 1.39) (95% CI: 0.28–2.50) (eta squared = 0.01) [Table 1].

Table 1.

Prevalence of risk factors in case and control groups

Risk factors	Case (n=288) n (%)	Control (n=234) n (%)	P	Effect size2
Age in years (Mean±SD)	48.8±15.54	44.0±15.76	0.001	0.02
Sex
Male	57 (19.79)	106 (45.30)	<0.001	0.27
Female	231 (80.21)	128 (54.70)
BMI1 (Mean±SD)	29.05 (6.59)	27.66 (6.31)	0.015	0.01
Hypertension	81 (28.13)	75 (32.05)	0.330	0.04
Diabetes Mellitus	87 (30.21)	60 (25.64)	0.249	0.05
Dyslipidemia	104 (36.11)	62 (26.50)	0.019	0.10
Systemic lupus erythematosus	0 (0)	2 (0.85)	0.200	0.07
Rheumatoid arthritis	5 (1.74)	3 (1.28)	0.736	0.02
Psoriasis	3 (1.04)	3 (1.28)	1.000	0.01
Celiac disease	1 (0.35)	0 (0)	1.000	0.04
Inflammatory bowel disease	0 (0)	2 (0.85)	0.200	0.07
Multiple sclerosis	0 (0)	2 (0.85)	0.200	0.07
Family history of thyroid disease	174 (60.42)	59 (25.21)	<0.001	0.35
Smoking	38 (13.19)	45 (19.23)	0.061	0.08
Alcohol	4 (1.39)	6 (2.56)	0.355	0.04
Previous radiation therapy	22 (7.64)	0 (0)	<0.001	0.19
Radioactive Iodine	16 (5.56)	0 (0)	<0.001	0.16
External radiation	6 (2.08)	0 (0)	0.035	0.10
Amiodarone	1 (0.35)	0 (0)	1.000	0.04
Steroids	16 (5.56)	9 (3.85)	0.363	0.04
Lithium	1 (0.35)	0 (0)	1.000	0.04

¹Body mass index; ²Eta squared was measured for independent samples t-test; Cramer’s V was measured for Chi-square test

A Chi-square test for independence examined the risk factors for cases and controls. There was no significant difference between cases and controls, for hypertension, DM, dyslipidemia, systemic lupus erytheromatosis, rheumatoid arthritis, psoriasis, celiac disease, inflammatory bowel disease, multiple sclerosis, smoking, alcohol, amiodarone, steroids, and lithium.

There was a significant difference (P < 0.05) between cases and controls for sex, dyslipidemia, family history of thyroid disorder, past radiation therapy, use of radioactive iodine, and external radiation [Table 1].

An independent-sample t-test was conducted to compare the associated risk factors for hyperthyroidism and control. There was a significant difference in the mean age of cases and controls (P < 0.02), 2-tailed. The mean age for hyperthyroidism was 49 (SD = 14.43) and for the controls was 44 (SD = 15.76). The magnitude of the difference in the mean age (mean difference = 4.99, 95% CI: 1.13–8.84) was small (eta squared = 0.02). There was no significant difference in BMI between hyperthyroidism and control (P > 0.71). The mean BMI for hyperthyroidism was 27.98 (SD = 7.11) in comparison to 27.66 (SD = 6.31) in controls. The magnitude of the differences in the mean BMI (mean differences = 0.32, 95% CI: −1.37 to 2.01) was very small (eta squared = 0.00).

A Chi-square test for independence indicated no significant difference between hyperthyroidism and controls for associated risk factors, including hypertension, diabetes mellitus, dyslipidemia, systemic lupus erytheromatosis, rheumatoid arthritis, psoriasis, coeliac disease, inflammatory bowel disease, multiple sclerosis, smoking, alcohol, and steroids (P > 0.05).

Nevertheless, there was a significant difference (P < 0.05) between hyperthyroidism and controls for sex, family history of thyroid disorder, past radiation therapy, and the use of radioactive iodine (P < 0.05) with moderate effect size (phi = 0.3–0.4) [Table 2].

Table 2.

Prevalence of risk factors in hyperthyroidism and control groups

Risk factors	Hyperthyroidism (n=76) n (%)	Control (n=234) n (%)	P	Effect size2
Sex
Male	18 (23.68)	106 (45.30)	<0.001	0.190
Female	58 (76.32)	128 (54.70)
Age (mean±SD)	49±14.4	44±15.8	0.015	0.019
BMI1 (mean±SD)	27.98±7.11	27.66±6.31	0.709	0.000
Hypertension	23 (30.26)	75 (32.05)	0.771	0.017
Diabetes Mellitus	21 (27.63)	60 (25.64)	0.731	0.019
Dyslipidemia	25 (32.89)	62 (26.50)	0.281	0.061
Systemic lupus erythematosus	0 (0)	2 (0.85)	1.000	0.046
Rheumatoid arthritis	0 (0)	3 (1.28)	1.000	0.056
Psoriasis	2 (2.63)	3 (1.28)	0.599	0.046
Celiac disease	1 (1.32)	0 (0)	0.245	0.100
Inflammatory bowel disease	0 (0)	2 (0.85)	1.000	0.046
Multiple sclerosis	0 (0)	2 (0.85)	1.000	0.046
Family history of thyroid disease	42 (55.26)	59 (25.21)	<0.001	0.276
Smoking	15 (19.74)	45 (19.23)	0.923	0.006
Alcohol	1 (1.32)	6 (2.56)	1.000	0.036
Previous radiation therapy	16 (21.05)	0 (0)	<0.001	0.409
Radioactive Iodine	15 (19.74)	0 (0)	<0.001	0.396
External radiation	1 (1.32)	0 (0)	0.245	0.100
Amiodarone	0 (0)	0 (0)	--------	--------
Steroids	5 (6.58)	9 (3.85)	0.343	0.057
Lithium	0 (0)	0 (0)	--------	--------

¹Body mass index; ²Eta squared was measured for independent samples t-test; Cramer’s V was measured for Chi-square test

A Chi-square test for independence was conducted to report the association of risk factors between the hypothyroidism group and control. It was found that there was a significant difference between the two groups (P < 0.05) for sex, dyslipidemia, FH of thyroid disorder, smoking, previous radiation therapy, and exposure to external radiation, with Cohen’s small effect size ranging from 0.12 for exposure to external radiation to 0.39 for family history of thyroid disorder. No significant association was reported (P > 0.05) for hypertension, diabetes mellitus, systemic lupus erytheromatosis, rheumatoid arthritis, psoriasis, inflammatory bowel disease, multiple sclerosis, alcohol, radioactive iodine exposure, amiodarone, steroid use, or lithium, with a small effect size.

An independent-sample t-test for continuous variables for mean age demonstrated a significant difference between the hypothyroidism group and control (P < 0.005). The mean age of hypothyroidism subjects was 50.17 (SD = 15.94) in comparison to 44.00 (SD = 15.76) in controls. The size of the difference in the means (mean difference = 6.17, 95% CI: 3.12–9.24) was very small (eta squared = 0.04). Similarly, the output of the independent-samples t-test for BMI showed a significant difference in hypothyroidism group and controls (P < 0.05). The mean BMI was 29.53 (SD = 6.35) and 27.66 (SD = 6.31) for the hypothyroidism group and the control group, respectively. The magnitude of the differences in the mean (mean difference = 1.87, 95%CI: 0.64–3.09) was small (eta squared = 0.02) [Table 3].

Table 3.

Prevalence of risk factors in hypothyroidism and control groups

Risk factors	Hypothyroidism (n=186) n (%)	Control (n=234) n (%)	P	Effect size2
Sex
Male	30 (16.13)	106 (45.30)	<0.001	0.310
Female	156 (83.87)	128 (54.70)
Age (mean±SD)	50.2±15.9	44±15.8	<0.001	0.036
BMI1 (mean±SD)	29.53±6.35	27.66±6.31	0.003	0.021
Hypertension	52 (27.96)	75 (32.05)	0.364	0.044
Diabetes Mellitus	58 (31.18)	60 (25.64)	0.209	0.061
Dyslipidemia	71 (38.17)	62 (26.50)	0.011	0.125
Systemic lupus erythematosus	0 (0)	2 (0.85)	0.505	0.062
Rheumatoid arthritis	5 (2.69)	3 (1.28)	0.475	0.051
Psoriasis	1 (0.54)	3 (1.28)	0.633	0.038
Celiac disease	0 (0)	0 (0)	--------	--------
Inflammatory bowel disease	0 (0)	2 (0.85)	0.505	0.062
Multiple sclerosis	0 (0)	2 (0.85)	0.505	0.062
Family history of thyroid disease	119 (63.98)	59 (25.21)	<0.001	0.390
Smoking	20 (10.75)	45 (19.23)	0.017	0.116
Alcohol	2 (1.08)	6 (2.56)	0.310	0.054
Previous radiation therapy	6 (3.23)	0 (0)	0.007	0.135
Radioactive Iodine	1 (0.54)	0 (0)	0.443	0.055
External radiation	5 (2.69)	0 (0)	0.017	0.123
Amiodarone	1 (0.54)	0 (0)	0.443	0.055
Steroids	9 (4.84)	9 (3.85)	0.618	0.024
Lithium	1 (0.54)	0 (0)	0.443	0.055

¹Body mass index; ²Eta squared was measured for independent samples t-test; Cramer’s V was measured for Chi-square test

The study showed the significant variables in bivariate analysis (in Chi-square or t-test). These were entered in binary logistic regression to explore the actual risk factors for all thyroid diseases. A 1-year increase in age is 1.02 times more likely to have thyroid disease (95% CI: 1.01–1.04). Moreover, female participants are 2.95 times more likely to have thyroid disease than males (95% CI: 1.93–4.50). Regarding family history, participants with a family history of thyroid disease are 4.36 more likely to have thyroid disease than participants without (95% CI: 2.90–6.55). Diabetes mellitus and dyslipidemia were studied in the binary logistic regression as they are major risk factors associated with thyroid disease. However, in this study, the results were not significant in regard to the likelihood of developing thyroid disease in participants with diabetes mellitus and dyslipidemia [Table 4].

Table 4.

Binary logistic regression of risk factors associated with thyroid disease

	Odds Ratio	95% CI for Odds Ratio	P
Age	1.028	(1.012, 1.044)	0.001
BMI	1.019	(0.988, 1.050)	0.238
Sex
Male (Reference)	2.954	(1.936, 4.507)	<0.001
Female
Diabetes mellitus
No (Reference)	0.834	(0.482, 1.442)	0.516
Yes
Dyslipidemia
No (Reference)	1.276	(0.722, 2.253)	0.402
Yes
Family History of Thyroid Disease
No (Reference)	4.360	(2.903, 6.550)	<0.001
Yes

Discussion

This paper represents the first study conducted in the Kingdom of Bahrain to examine the risk factors associated with thyroid diseases. These factors include age, sex, hypertension, diabetes mellitus, dyslipidemia, systemic lupus erythematosus, rheumatoid arthritis, psoriasis, celiac disease, inflammatory bowel disease, multiple sclerosis, family history of thyroid disease, smoking, alcohol consumption, previous radiation therapy, amiodarone usage, steroids usage, and lithium usage. The study also aimed to determine the prevalence of abnormal thyroid tests conducted in the year 2022 in the Kingdom of Bahrain among adults who attended primary healthcare.

While global statistics reported separate prevalence rates for each thyroid disease, no previous study documenting the prevalence of abnormal thyroid tests was found. Our primary outcome was to evaluate the prevalence of abnormal thyroid tests that were done in the year 2022, which was found to be 11.5%.

The study included two groups, each starting with 500 participants. After excluding individuals who did not meet the inclusion criteria or failed to respond after multiple attempts, the final analysis included 288 patients in the case group and 234 patients in the control group.

Within the case group, participants were further categorized into four subgroups: hyperthyroidism (26.4%), hypothyroidism (64.6%), subclinical hyperthyroidism (4.5%), and subclinical hypothyroidism (4.5%). The highest percentage was observed in the hypothyroidism subgroup (64.6%). These findings align with global statistics, indicating that hypothyroidism is the most prevalent among thyroid diseases. Similar results were reported in a study conducted by Gupta et al.[26] in Nepal, where the percentage of hypothyroidism was 76% compared to 24% for hyperthyroidism.

When assessing the secondary outcomes by examining individual risk factors, it was found that the mean age of the case group was higher than that of the control group, indicating a positive association between increasing age and the presence of thyroid diseases. This finding was consistent with previous studies conducted in China, the UK, Egypt, and Riyadh, which also reported a higher risk of developing thyroid disease with increasing age.[19,14,27,28]

Furthermore, a higher percentage of cases were seen among females in comparison to the controls. This aligns with findings by Vanderpump and Alqahtani, who reported a higher prevalence of thyroid disease among females than males.[29,30] Studies conducted in Saudi Arabia also revealed a higher prevalence of hypothyroidism and hyperthyroidism in females compared to males.[31,32]

In addition, this study identified a relationship between high body mass index (BMI) and hypothyroidism. This was consistent with findings by Ogbonna and Ezeani, as well as Mahdavi et al., who reported significantly higher BMI among individuals with thyroid disease.[18,33]

Notably, our study found a significant association between hypothyroidism and hyperlipidemia. This corroborates the findings of S. Martin et al., who noted a strong link between hyperlipidemia and thyroid disease compared to diabetes or high blood pressure.[17]

Moreover, family history was identified as a significant risk factor for thyroid diseases, as supported by previous studies done in Saudi Arabia and Sweden conducted on patients with hypothyroidism and hyperthyroidism.[10,34]

On the contrary, several studies hypothesized that there is an association between hypertension, diabetes mellitus, and thyroid disease.[2,10,14,18,35,36] Regarding other autoimmune diseases, several studies showed that thyroid disease is linked to systemic lupus erythematosus, celiac disease, inflammatory, rheumatoid arthritis, psoriasis, and multiple sclerosis.[22,23,37,38,39,40]

Moreover, several studies confirmed that previous radiation therapy (both external and internal radiation), amiodarone, steroids, and lithium correspond with the existence of thyroid disease.[19,20,41,42] Regarding socioeconomic factors, smoking and alcohol were found to be associated with a lower risk of developing thyroid disease.[3]

Nonetheless, our study did not reach the same conclusion for the previously mentioned risk factors (P > 0.05). This could be due to the limitation of the selected sample size and the duration of the study in comparison to previous studies.[3,10,19,36,43]

Limitations

Several limitations were encountered during this study. First, the sample size obtained was smaller than initially anticipated. This was due to the inability to exclude certain patients before selecting the random sample as the process had to be done manually due to insufficient data received from the HID. Second, the response rate obtained was lower than desired, likely attributed to factors such as patients changing their contact information, providing incorrect contact details, or being unavailable due to travel.

In addition, patients who sought follow-up care in the private sector were not included in the study due to a lack of a shared data system with the primary healthcare centers. Furthermore, the limited duration of 1 month for data collection posed a constraint on the study’s findings.

Moreover, it is important to acknowledge the presence of recall bias as patients may have difficulties accurately recalling certain details such as their weight, height, and previous medications taken.

Recommendations

Given the significant associations observed between certain risk factors and thyroid disease, we recommend the implementation of a national screening program in the Kingdom of Bahrain. This program should target individuals with increasing age, female sex, or a family history of thyroid disease as these risk factors have serious implications.

Efforts should be focused on increasing the demand for screening through patient education initiatives. These initiatives could include advertisements, newsletters, and improved communication with healthcare providers. Regular reminders should be provided to healthcare providers regarding the importance of screening in reducing morbidity and mortality.

For future endeavors, a national awareness campaign can be developed. This campaign should aim to educate individuals about the consequences of thyroid disease and encourage them to visit their nearest healthcare center for testing.

Conclusion

In summary, the prevalence of abnormal thyroid tests in the Kingdom of Bahrain attending primary healthcare centers in 2022 was found to be 11.5%, highlighting the need for an organized screening program for individuals at average risk of developing thyroid disease.

The most prevalent risk factors identified for thyroid disease were increasing age, female sex, family history of thyroid disease, previous radiation therapy, and dyslipidemia.

Furthermore, future studies should be aimed at investigating the complications associated with thyroid disease in the Kingdom of Bahrain to gain a better understanding of the disease’s impact.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Appendix 1: Risk Factors Associated with Thyroid Disease Questionnaire

Demographic characteristics:

 • Age: -----------------

 • Sex: □ Female □ Male

Co-morbidities

 □ HTN □ DM □ Dyslipidemia □ SLE □ RA □ Psoriasis □ Celiac disease

 □ IBD □ MS

Family history of thyroid disease:

 □ Yes: -----------------

 □ No

Social history:

 □ Smoking □ Alcohol

Weight: -----------------

Height: -----------------

(BMI): -----------------

Previous radiation therapy:

 □ Yes: time and duration: -----------------

 □ No

Current Medications:

 □ Antithyroid drugs

 □ Thyroxine

 □ Amiodarone

 □ Steroids

 □ Lithium