Thyroid Health Feedback Form
Please provide your feedback regarding your thyroid health, symptoms, and related experiences. Your responses will help us better understand thyroid health concerns.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Female
Male
Other / Prefer not to say
Have you been diagnosed with a thyroid condition?
*
Yes, Hypothyroidism
Yes, Hyperthyroidism
Yes, Other thyroid condition
No diagnosis
Please rate the severity of the following symptoms experienced in the last month.
*
Rows
None
Mild
Moderate
Severe
Fatigue
1
2
3
4
Weight changes
5
6
7
8
Hair loss
9
10
11
12
Mood changes (anxiety, depression)
13
14
15
16
Sensitivity to cold/heat
17
18
19
20
Neck swelling or discomfort
21
22
23
24
Heart palpitations
25
26
27
28
Are you currently taking any medication for your thyroid condition?
*
Yes
No
Not applicable
When was your last thyroid function test?
*
Please Select
Within the last 3 months
3-6 months ago
6-12 months ago
Over a year ago
Never tested
How would you describe your overall well-being currently?
*
1
2
3
4
5
Which lifestyle factors do you feel most impact your thyroid health? (Select all that apply)
Diet/nutrition
Physical activity
Stress
Sleep quality
Other
Please share any additional comments or feedback about your thyroid health experience.
Email Address (optional, for follow-up if needed)
example@example.com
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