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Thyroid Function Monitoring Chart

A Personal Progress Tracking Tool for Thyroid Patients

Endocrinology

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Template Content

Last updated: Mar 24, 2025

Patient Information

Name: _________________ Date of Diagnosis: _________________ Treating Physician: _________________

Laboratory Values Tracker

TSH Levels

Date Result Reference Range Notes
0.4-4.0 mIU/L
0.4-4.0 mIU/L
0.4-4.0 mIU/L

Free T4 Levels

Date Result Reference Range Notes
0.8-1.8 ng/dL
0.8-1.8 ng/dL
0.8-1.8 ng/dL

Symptom Tracker

Rate symptoms from 0 (none) to 5 (severe)

Date: _________________

  • Fatigue: ___
  • Weight changes: ___
  • Temperature sensitivity: ___
  • Mood changes: ___
  • Sleep quality: ___

Medication Log

Medication Dose Start Date Changes

Additional Notes

Next Appointment

Date: _________________ Time: _________________

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