#1 Do you experience pain with your thyroid condition?
If so, what is your level of pain?
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#2 Do you have a problem with fatigue?
If so, what is your level of fatigue?
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#3 Do you experience coldness in your hands or feet?
If so, how bad has the coldness been?
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#4 Have you had more than one or two headaches the past month?
If so, how intense have your headaches been?
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#5 Do you have trouble sleeping?
If so, how disrupted has your sleep been?
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#6 Do you have trouble falling asleep or staying asleep, or both ?
-Please select one-
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Falling Asleep
Staying Asleep
Both
#7 Do you have bowel or digestive problems?
If so, how disrupted has your bowel function been?
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#8 Have you had trouble with depression or anxiety?
If so, how depressed or anxious have you been?
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#9 Do you have trouble losing weight?
#10 Have you had problems with your memory or concentration?
If so, how bad has your memory and/ or concentration been?
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#11 Do you experience numbness or tingling in your hands or feet?
#12 Have you been diagnosed with Hashimoto's?
#14 How has your life changed since your thyroid began to be a problem?
#15 Since you've suffered from your thyroid problem, what three things have you missed doing the most?
#16 What are your top 2 questions you would like the doctor to answer in the Initial Consultation?
#17 Why do you think that you would be a good candidate for our program?
#19 How Committed Are You To Getting Into Our Program and Reversing Your Thyroid Problem Naturally and Scientifically?
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