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Thyroflex Assessment Questionnaire
Δ
GHC Thyroflex Form
First Name
Last Name
Email
Date of Birth
Weight
Height
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.
Tiredness & Sluggishness, Lethargic
0
1
2
3
Dryer Hair or skin (thick, dry, scaly)
0
1
2
3
Sleep more then usual
0
1
2
3
Weaker muscles
0
1
2
3
Constant feeling of cold (fingers / hands / feet)
0
1
2
3
Frequent muscle cramps
0
1
2
3
Poorer memory
0
1
2
3
More deppressed (mood change easily)
0
1
2
3
Slower thinking
0
1
2
3
Puffier eyes
0
1
2
3
Difficulty with math
0
1
2
3
Hoarser or deeper voice
0
1
2
3
Constipation
0
1
2
3
Coarse hair / hair loss / brittle
0
1
2
3
Muscle / joint pain
0
1
2
3
Low sex drive / Impotence
0
1
2
3
Puffy hands / feet
0
1
2
3
Unsteady gait (bump into things)
0
1
2
3
Gain weight easily
0
1
2
3
Outer third of eyebrows thin
0
1
2
3
Carpel tunnel syndrome
0
1
2
3
Menses more regular (should be 28 days)
0
1
2
3
Heavier menses (clotting / 3+ days)
0
1
2
3
TOTAL Hypo score=
Palpitaitons
0
1
2
3
Insomnia
0
1
2
3
Tachycardia (rapid or irregular heart beat)
0
1
2
3
Shakiness
0
1
2
3
Increased sweating
0
1
2
3
Brittle nails
0
1
2
3
Loss of appetite
0
1
2
3
TOTAL Hyper score=
Stress Modulators (DHEA/D3/Prgenen/GABA + B’s)
Constantly exhausted & tired
0
1
2
3
Cannot tolerate noise
0
1
2
3
My libido is low
0
1
2
3
Muscles are getting flaby (loosing muscle tone)
0
1
2
3
TOTAL Stress Modulator score=
Adrenals (Cortisol)
Rapid heart beat
0
1
2
3
I’m stressed out
0
1
2
3
Easily confused
0
1
2
3
Digestive problems
0
1
2
3
Have eczema, psoriasis, skin allergies, rashes
0
1
2
3
Wake up tired
Yes
No
Wake up full of energy
Yes
No
2-4pm feel tired, seek snack salty/sweet, tea, coffee, soda
Yes
No
Fall asleep in front of TV/ reading / computer / (before bed)
Yes
No
As soon as I go to bed – drop straight to sleep
Yes
No
Need to read/TV – 10-15 min to drift into sleep
Yes
No
TOTAL Adrenal score=
Iodine/Iodide
FBD / lumps / ovarian cysts / uterine fibroids / prostate
0
1
2
3
Goiter buldge or band aorund the neck
0
1
2
3
Slow speech
0
1
2
3
Enlarged tongue / teeth impressions
0
1
2
3
Puffy face / hands
0
1
2
3
TOTAL Iodine/Iodide Symptoms score=
Do you use salt with Iodine added?
Yes
No
Number of days a week you eat seafood / shellfish
TOTAL Iodine in score=
Melatonin, Serotonin, Tryptophan
Upon waking feel tired
0
1
2
3
Wake up during the night
0
1
2
3
If awaking, (in the middle of the night), cannot get back to sleep
0
1
2
3
Trouble falling asleep
0
1
2
3
Use a sleep aid, or drink alcohol to relax
0
1
2
3
My mind is busy when I want to sleep
0
1
2
3
TOTAL Melatonin score=
CoQ10
Do you have stamina?
Yes
No
ACTH
Do you lack will power & energy
Yes
No
Patches of hair loss ( alopecia )
Yes
No
Pale complexion / sunburn easily
Yes
No
Often have memory loss
Yes
No
FOR PRACTITIONER TO FILL:
Please enter a dash (-) or zero (0) in these sections.
TOTAL ACTH
TOTALS
Hypo/Hyper=
Reflex time=
RMR=
Submit Form
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EPIGENETICS WELLBEING ASSESSMENT
SERVICES
Epigenetics Wellbeing Assessment
Health Assessments
Immunity Assessment
Stress assessment
Thyroid health
Beat Fatigue
Beat fatigue
Wellbeing Programmes
Anti-aging
Energy and vitality
Peak performance
Weight loss
Body Therapies
Mind Therapies
All Services
SHOP
Epigenetics Wellbeing Assessment
Supplements
Stress/Fatigue/Hormones
Digestion/Regularity
Relaxation/Sleep Support
Immunity Boost
General Wellbeing Support
Practitioner Only
Accessories/Books/Earthing
Water/Protein Powder/Oils
Electrical Sensitivity/EMF Protection
Browse all products
Search
My account
VIDEOS
Client Testimonial Videos
Health Topics & Tips
Global Health TV Show
Bruce Lipton Videos
Dr Daryl Turner Videos
BLOG
TEAM
John Coombs
Stefan Sageman
Hester Scott
Vivienne Berry
Fi Rutland
Jeejo Murickan
BOOK ONLINE
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