THYROID SURVEY – Do you suffer from any of the following?
Please Rate your symptoms below in Numbers only, in a scale of 0, 1, 2 or 3
( 0= None, 1= Mild, 2= Moderate, 3= Severe OR if indicated Yes =1 and No = 0)
THYROID SURVEY
Thyroid - _____ Tiredness & Sluggishness, lethargic
- _____ Dryer Hair or Skin (Thick,dry,scaly)
- _____ Sleep More Than Usual
- _____ Weaker Muscles
- _____ Constant Feeling of cold (finger / hands/ feet)
- _____ Frequent Muscle Cramps
- _____ Poorer Memory
- _____ More Depressed (mood Change easily)
- _____ Slower Thinking
- _____ Puffier Eyes
- _____ Difficulty with Math
- _____ Hoarser or Deeper Voice
- _____ Constipation
- _____ Coarse Hair / Hair loss / brittle
- _____ Muscle / Joint Pain
- _____ Low Sex Drive / Impotence
- _____ Puffy Hands and Feet
- _____ Unsteady Gait (bump into things)
- _____ Gain Weight Easy
- _____ Outer Third Of Eyebrows Thin
- _____ Menses More Irregular ( should be 28 Days)
- _____ Heavier Menses (clotting / 3+ days)
- _____ Carpel Tunnel Syndrome
_______ Total HYPO Score (8) - _____ Palpitations (Skipping of heart beat)
- _____ Insomnia
- _____ Tachycardia (Rapid or irregular heart beat)
- _____ Shakiness
- _____ Increased Sweating
- _____ Brittle Nails
- _____Loss of Appetite
_______ Total HYPER Score (0) DHEA - ______Constantly exhausted & tired
- ______Cannot tolerate noise
- ______My Libido is low
- ______Muscles are getting flabby (Loosing muscle tone)
________Total DHEA (2) | Adrenals (Cortisol) - ____Rapid heart beat
- ____I’m stressed out
- ____Have eczema, psoriasis, skin allergies, rashes
- ____Digestive problems
- ____Easily confused
- ____Wake up tired (The following 6xQ’s are: Y=1, N=0↓ )
- ____Wake up full of energy Y/N
- ____2 to 4 pm feel tired, seek snack/Tea/Coffee/Coke Y/N
- ____Fall asleep in front of TV/reading/computer (before bed)Y/N
- ____As soon as I go to bed-Drop straight to sleep Y/N
- ____Need to read/TV -10 to 15 mins to drift into sleep Y/N
________Total Adrenal (3) Iodine/Iodide - _____Fibrocystic Breast / lumps/ ovarian cysts
- _____Goiter Bulge or Band Around the Neck
- _____Slow Speech
- _____Enlarged tongue
- _____Puffy Face /Puffy Hands
________Total Iodine/Iodide Symptoms (0) - _____Do you use salt with Iodine added Y=1 N=0
- _____Number of days per week you eat seafood/shellfish**(Excludes Salmon/Canned Tuna/Tilapia/Trout/Fresh water fish)
________Total Iodine Intake (6) Melatonin, Serotonin, Tryptophan - _____Upon waking feel tired
- _____Wake up during the night
- _____If awakening,( in middle of night),cannot get back to sleep
- _____Trouble falling asleep
- _____Use a sleep aid, or drink Alcohol to relax
- _____My mind is busy when I want to sleep
_______Total Melatonin (2) ACTH - _____Do you lack willpower & energy Y=1, N=0
- ____Patches of hair loss Y=1, N=0
- ____Pale complexion/sunburn easily Y=1, N=0
- _____Often have Memory Loss Y=1, N=0
________Total ACTH (2) |
Your scores should be under the “total” number listed at the bottom of each section.
CLICK HERE for FREE thyroid testing (valued at $140) with an initial consult until 28th Feburary 2017.
Contact me at julie@feelinggreatnaturopath.com.au and enquire about how I can help you feel great again.
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