Thyroflex Assessment Questionnaire

GHC Thyroflex Form


Thyroid


Rate your symptoms below from a scale of 0-3 ( 0= none, 1= mild, 2= moderate, 3= severe)

Please answer all questions appropriate for you.

Stress Modulators (DHEA/D3/Prgenen/GABA + B’s)


Adrenals (Cortisol)


Iodine/Iodide


Melatonin, Serotonin, Tryptophan


CoQ10


ACTH


FOR PRACTITIONER TO FILL:

Please enter a dash (-) or zero (0) in these sections.