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.