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Resistance to thyroid hormone
Name:
Date of Birth:
MRN Number:
Family Number:
Phenotype Present
Phenotype Description
Unknown Yes No
Primary hypothyroidism
Central hypothyroidism
Hypothalamic hypothyroidism
Pituitary hypothyroidism
Thyroid agenesis
Thyroid hypoplasia
Ectopic thyroid
Goiter
Thyroid defect in oxidation and organification of iodide
Thyroid-stimulating hormone excess
Decreased T3/T4 ratio
Increased T3/T4 ratio
Increased serum free triiodothyronine (fT3)
Thyroid hormone receptor defect
ADDITIONAL PHENOTYPING
Phenotype Description
Phenotype Present
Unknown Yes No
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