Hashimoto's Disease Symptom Survey
Help us better understand your experience with Hashimoto's Disease by completing this confidential symptom survey.
Full Name
*
First Name
Last Name
Email Address (for follow-up, if needed)
example@example.com
Age
*
Gender
*
Female
Male
Non-binary
Prefer not to say
Other
Have you been formally diagnosed with Hashimoto's Disease?
*
Yes, by a healthcare professional
Suspected, but not formally diagnosed
No
How long have you experienced symptoms related to Hashimoto's Disease?
*
Please Select
Less than 6 months
6 months to 1 year
1-3 years
More than 3 years
Not sure
Are you currently receiving treatment for Hashimoto's Disease?
*
Yes, medication prescribed
Yes, lifestyle/diet changes only
No treatment
Please rate the severity of the following symptoms you have experienced in the past month:
*
Rows
None
Mild
Moderate
Severe
Fatigue
1
2
3
4
Weight gain
5
6
7
8
Hair loss
9
10
11
12
Dry skin
13
14
15
16
Cold intolerance
17
18
19
20
Muscle/joint pain
21
22
23
24
Depression/anxiety
25
26
27
28
Brain fog (difficulty concentrating)
29
30
31
32
Constipation
33
34
35
36
Swelling of neck (goiter)
37
38
39
40
How would you rate your overall quality of life in the past month?
*
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
How often do your symptoms interfere with your daily activities or work?
*
Never
Rarely
Sometimes
Often
Always
Please share any additional comments or symptoms you would like us to know about.
Submit Survey
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