NATUROPATH | THRYOID & HORMONE HEALTH | FOOD ALLERGIES | DIGESTIVE HEALTH | WEIGHT LOSS

Thyroid Questionnaire

Thyroid questionnaire

Do you suffer from any of the following symptoms?

Please rate your symptoms below from a scale of 0-3
0-None
1-Mild
2-Moderate
3-Severe

___Tired and Sluggish, lethargic
___Dry hair and skin (Thick, dry, scaly)
___Increased need for sleep
___Weak muscles
___Constant feeling of cold (Fingers/hands/feet)
___Frequent muscle cramps
___Poor memory
___Depressed (Mood changes easily)
___Slow thinking
___Puffy eyes
___Difficulty with math
___Hoarser or deeper voice
___Muscle and/or joint pain
___Constipation
___Coarse hair, hair loss, brittle hair
___Low sex drive or impotence
___Puffy hands and feet
___Unsteady gait (bump into things)
___Gain weight easily
___Thinning of outer eyebrows
___Menses more irregular (Should be 28 days)
___Heavier menses (3+ days)
___Carpel Tunnel Syndrome

TOTAL HYPO SCORE _____

___Tachycardia (Rapid heart beat)
___Palpitation (Skipping of heart beat)
___Insomnia
___Shakiness
___Increased Sweating
___Brittle Nails
___Loss of Appetite

TOTAL HYPER SCORE _____

If you score higher than 8 in the Hypo section or higher than 0 then you would benefit from booking in for a thyroid wellness consultation.

Please phone 09 963 7396 to book an appointment.

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