Barriers to Thyroid Hormone Absorption Questionnaire To help understand how you take your thyroid, please participate in this survey. Participation is completely voluntary and the information collected will be kept anonymous – this means that your name and other identifying information is not asked for and not used. This information may be used for future publication. You can refuse to participate and such a decision will not affect your medical care at Boston Medical Center, now or in the future. If you have additional questions, please contact Dr. Stephanie Lee at 617-638-8530. This survey should take about ten minutes to complete. THANK YOU FOR YOUR TIME. How old are you? _______ Sex: Female/Male Height:________ Weight: ________ Which of the following best describes you? (Please circle all that apply) Alaskan Native American Indian Asian Black Hispanic Middle Eastern Mixed Race/Ethnicity Pacific Islander White Other: __________________ Education: (Please circle level of highest education completed) Grade School High School College Graduate School (Primary School) (Secondary School) (University) (Graduate/Professional School) Marital Status: (Please circle one) Divorced Married Separated Single Annual Household Income: (Please circle one) <$20,000 $20,001-$50,000 $50,001-$100,000 >$100K |