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Thyroflex Assessment Questionnaire
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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Health Assessments
Epigenetics Wellbeing hair test
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
TEAM
John Coombs
Dr Vanessa Ingraham
Stefan Sageman
Hester Scott
Vivienne Berry
Fi Rutland
Craig Lyle
Jeejo Murickan
SHOP
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
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VIDEOS
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