Thyroflex Assessment Questionnaire

Skip to content

MY WELLBEING SOLUTIONS
Blood Wellbeing
SERVICES
SHOP
Videos
Blog
Team
Book Online

MY WELLBEING SOLUTIONS
Blood Wellbeing
SERVICES
SHOP
Videos
Blog
Team
Book Online

Search

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) Women to answer*

0 1 2 3

Heavier menses (clotting / 3+ days) Women to answer*

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 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=

let’s talk

Contact us for info & bookings

Schedule a free consultation with our team and let’s make things happen!

Contact us

409 Lake Road Takapuna Auckland 0622
+64 9 488 0208
Reception hours: Mon-Fri 9.30am-6pm

Email Us Now

Online Consultations Available.

Important Notices

Legal Medical Disclaimer
Privacy Policy
Terms of Service

Legal Medical Disclaimer
Privacy Policy
Terms of Service

Our Affiliate Sites

Ozone Health Website
Cell Wellbeing Website
Beat Fatigue Website
Lifestyle Hypnosis Website
My Wellbeing Website

Ozone Health Website
Cell Wellbeing Website
Beat Fatigue Website
Lifestyle Hypnosis Website
My Wellbeing Website

Subscribe to our mailing list

Email

Built by Magcaling Co

Facebook-f Youtube Instagram