Hypothyroidism

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Q51 CONSENT AGREEMENT 

You are invited to be a part of our hypothyroidism and brain fog study. Your participation
would invaluable to our efforts to study hypothyroidism and the impact it has on mental and
personal well-being. 

If you agree to participate, you will be asked to fill out a brief survey questionnaire consisting of
a demographic section, depression screening, anxiety screening, and a brain fog survey.

As a token of appreciation, you will receive a $10 gift card upon completion of the survey.

Additionally, if you agree to participate, we are asking permission to access your medical
records to obtain information pertinent to our ongoing research study on hypothyroidism and
brain fog. 

You will not be asked to put your name on the survey. Further details of this study are outlined
below.

What happens if I refuse to participate or want to stop my participation in the study?

You are free to refuse to participate in this research project or to withdraw your consent and
discontinue participation in the project at any time without penalty or loss of benefits to which
you are otherwise entitled. Your decision to not to participate will not affect your relationship
with the institution(s) involved in this research project. 

What will happen to my responses and data? 

All your information will be de-identified (will not be traceable back to you) and kept confidential.
After completion of questionnaire, the use of your responses will limited to our current study and
will not be used or distributed after the commencement of this study for any purpose. 

How long will it take me to complete the survey?

It will take you approximately 15 minutes to complete the survey. 

Are there any risks to me for participating in the study?

There have been no identified risks to your health or personal safety regarding your participation
in this study. However, as with any attempt to collect data, there remains a minimal risk that
there could be a loss of confidentiality regarding your data and responses. Please be assured
that the appropriate steps will be taken to ensure your information is securely stored, de-
identified, and only available to members of the research team.

If you have any concerns, please contact a team member or contact the University Institutional
Review Board (contacts listed below). 

What are the potential benefits of participating in the study?

While there is no direct benefit to you, the outcomes of this study may improve the
understanding and treatment of those with hypothyroidism, and ultimately may lead to better
health outcomes. 

Will anyone, besides the research team, know about my involvement in this study or
have access to my records and questionnaire data? 
If required by law, staff of Central Michigan University and government agencies who ensure the
protection of human subjects in research may examine your records. 

How is this study being funded? 

This work is financially supported by the principal investigator’s education fund.

How can I contact a member of the research team?

To speak with someone on the research team regarding the nature or subject of the research,
research participant rights, or to report a research-related injury, please call Dr. Sethu Reddy at
(989) 774-1258.

How can I contact someone outside the research team for information about this study?
To talk to someone other than the researcher(s) about your rights as a research participant,
obtain general information, report a research-related injury, discuss any concerns about this
study, or to ask questions, please contact: 

Central Michigan University Institutional Review Board

Address: 600 East Preston Street, Foust Hall 104 Mount Pleasant, MI 48859
Phone: (989) 774-6401
Email: IRB@cmich.edu

 
Q56   Statement of Consent 
o By clicking this, I consent to participate in the survey and that I am 18 years of age. I
have read and understood the Consent Agreement. (1)
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Q3 What is your date of birth? Ex: MM/DD/YYYY
________________________________________________________________
Q57 What are your initials? Ex: Joe Smith = JS
________________________________________________________________
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Q51 Have you had COVID-19 in the past 12 months?
o Yes (1)
o No (2)
Display This Question:
If Have you had COVID-19 in the past 12 months? = Yes
Q55 If you have experienced mental symptoms after COVID, have you fully recovered from it?
o I have NOT experienced mental symptoms due to COVID (1)
o I have fully recovered from mental symptoms (2)
o I have NOT fully recovered from mental symptoms (3)
Q53 Do you have a history of cognitive decline (dementia, stroke, etc.)?
o Yes (1)
o No (2)
Have you ever been diagnosed with cancer?
o Yes (1)
o No (2)
Q3 Are you currently pregnant?
o Yes (1)
o No (2)
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Q50 What is your biological sex? 
o Male (1)
o Female (2)
o Prefer not to say (3)
Age What is your age (yrs)?
0 100
Age ()
Q47 What is your weight (lbs)?  
50 500
Weight (lb.) ()
Q48 What is your height? (Ex: if 5'0'', Move the 1st bar to 5 feet, and the 2nd bar to 0 inches)
 1 1 1
0 1 2 4 5 6 7 8
0 1 2
 Feet ()

Inches ()
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Q4 Which one of these best describes your ethnic group?
o White (non-Hispanic) (1)
o Black (non-Hispanic) (2)
o Hispanic (3)
o Asian or Pacific Islander (4)
o American Indian/Alaska Native (5)
o Other (6) __________________________________________________
Q5 What is the highest level of education you have completed?
o Some High School, but no diploma (1)
o High School graduate, diploma, or the equivalent (ie GED) (2)
o Some College (3)
o Undergraduate Degree (4)
o Master’s Degree (5)
o Doctorate Degree (6)
Q6 What is your marital status?
o Married (1)
o Divorced (2)
o Single (3)
o Other (4) __________________________________________________
Q52 What is your employment status?
o Employed (1)
o Unemployed (2)
o Student (3)
o Retired (4)
o Other (please specify) (5)
__________________________________________________
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Q7 Have you ever been diagnosed with hypothyroidism?
o Yes (1)
o No (2)
Display This Question:
If Have you ever been diagnosed with hypothyroidism? = Yes
Q8 How long ago were you diagnosed with hypothyrodism?
________________________________________________________________
Display This Question:
If Have you ever been diagnosed with hypothyroidism? = Yes
Q9 Are you currently taking medications for hypothyroidism?
o Yes (1)
o No (2)
Display This Question:
If Are you currently taking medications for hypothyroidism? = Yes
Q10 Have there been any recent changes (in dosage, frequency, or type) in your medications
for hypothyroidism within the last 6 months?
o Yes (1)
o No (2)
o Does not apply (Not taking medications) (3)
Skip To: End of Survey If Have there been any recent changes (in dosage, frequency, or type) in your
medications for hypoth... = Yes
Q11 Have you ever been diagnosed with Depression?
o Yes (1)
o No (2)
Q13 Have you ever been diagnosed with Anxiety?
o Yes (1)
o No (2)
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Q42 Brain fog is commonly referred to a constellation of symptoms that affect your ability to
think or perform basic tasks.
For example, you might feel confused, have difficulty concentrating, or difficulty articulating your
thoughts. It can be
 thought of as a kind of “mental fatigue”. Please consider this while answering the following
questions:
 I do not
Afternoon No Pattern experience
Morning (1) Evening (3) Night (4)
(2) (5) brain fog
(6)
When do
you
experience
the most
severe
brain fog? o o o o o o
(you may
check
several
boxes) (1)
Skip To: End of Survey If Brain fog is commonly referred to a constellation of symptoms that affect your
ability to think o... = I do not experience brain fog
Q44 On the chart below, we have listed several questions on the left hand side. Please check
one box indicating your response to the question. 
 I do not
Slightly (1) Moderately (2) Severely (3) experience brain
fog (4)
To what extent
has brain fog
affected your
Productivity?
(e.g work,
o o o o
school, chores,
etc) (1)
To what extent
has brain fog
affected your
Decision
o o o o
making? (2)
To what extent
has brain fog
affected your
Attention span?
o o o o
(3)
To what extent
has brain fog
affected your
ability to learn o o o o
and retain new
information? (4)
To what extent
has brain fog
affected your
Social activities/
o o o o
encounters? (5)
To what extent
has brain fog
affected your o o o o
Creativity? (6)
To what extent
has brain fog
affected your
General o o o o
temperament?
(7)
Q45 On the chart below, we have listed several symptoms on the left hand side. We would like
to know about how often you may be having a particular symptom. (Please check one box that
best corresponds to your situation).
 More than 5
2-5 days a Once a week 1-2 times a
days a week Never (5)
week (2) (3) month (4)
(1)

Forgetfulness
(1) o o o o o
Difficulty
thinking (2) o o o o o
Difficulty
focusing (3) o o o o o
Cloudy
thoughts (4) o o o o o
Difficulty
communicatin
g (5)
o o o o o
Mental
fatigue (6) o o o o o
Mentally slow
(7) o o o o o
Mind going
blank (8) o o o o o
Feeling
spacey (9) o o o o o
Difficulty
processing
what others o o o o o
say (10)

Exhausted
(11) o o o o o
Easily
distracted
(12)
o o o o o
Difficulty
processing
words when o o o o o
reading (13)

Confusion
(14) o o o o o
 Feeling
annoyed (15) o o o o o
Sleepy (16) o o o o o
Feeling lost
(17) o o o o o
Feeling
detached (18) o o o o o
Thoughts
moving too
quickly (19)
o o o o o
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