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Part 1: Multi Symptom Questionnaire
Rate each of the following symptoms based upon your typical health profile the past 30 days
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
Digestive Tract
Rate each of the following symptoms based upon your typical health profile the past 30 days
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
Ears
Rate each of the following symptoms based upon your typical health profile the past 30 days
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
Emotions
Rate each of the following symptoms based upon your typical health profile the past 30 days
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
Energy/Activity
Rate each of the following symptoms based upon your typical health profile the past 30 days
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
Eyes
Rate each of the following symptoms based upon your typical health profile the past 30 days
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
Head
Rate each of the following symptoms based upon your typical health profile the past 30 days
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
Heart
Rate each of the following symptoms based upon your typical health profile the past 30 days
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
Joints/Muscles
Rate each of the following symptoms based upon your typical health profile the past 30 days
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
Lungs
Rate each of the following symptoms based upon your typical health profile the past 30 days
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
Mind
Rate each of the following symptoms based upon your typical health profile the past 30 days
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
Mouth/Throat
Rate each of the following symptoms based upon your typical health profile the past 30 days
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
Nose
Rate each of the following symptoms based upon your typical health profile the past 30 days
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
Skin
Rate each of the following symptoms based upon your typical health profile the past 30 days
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
Weight
Rate each of the following symptoms based upon your typical health profile the past 30 days
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
Other
Part 2: Thyroid Symptom Questionnaire
This questionnaire helps you determine the function of thyroid hormone in your body. Regardless if you have had a lab test that say your thyroid is normal or that you may be taking prescription thyroid medication, you still may have problems with metabolism that directly relate to how thyroid hormone is functioning in your body.
In front of each question score the following from 0-10
For example,
10 = If this is a noticeable issue or significant problem nearly all the time;
7 = this is a noticeable issue or significant problem some of the time;
5 = If this is a problem you are aware of, but not a major issue in your life currently;
2 = If this happens every now and then, but you don't notice it too much and are not concerned;
0 = If you rarely or never have this issue
Step 3: Schedule Your Discovery Call to discuss your results
You will be redirected to schedule on the next page after you hit SUBMIT
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