• Thyroid Health Questionnaire

  • Format: (000) 000-0000.
  • Date of birth*
     - -
  • Blood type*

  • Please base your answers on how you have been feeling and experiencing in general during the past 4 weeks.

  • Has your thyroid imbalances affected your appearance for example, hair loss, swelling of the neck, eye changes, weight changes?*
  • Felling brain fog and slow or unclear thinking?*
  • Have a tendency to feel tired and fatigued a lot?*
  • Have Hormone imbalances?*
  • Have an upset or bloated stomach?*
  • Have constipation?*
  • Have difficulty getting motivated for normal lifestyle activities?*
  • Increased sensitive to heat or cold?*
  • Noticed you easily feel stressed?*
  • Have difficulty being together with other people, for example, spouse, children, boy/girlfriend, friends, or others?*
  • Has your thyroid Symptoms influenced which clothes you wear?*
  • Has your thyroid Imbalance had a negative effect on your quality of life?*
  • Are you currently working with a holistic practitioner?*
  • Not be able to participate in life around you?
  • Loss of hair
  • Should be Empty: