Do you struggle with any of these symptoms?
Fatigue
Brain Fog
Trouble Falling Asleep
Maintaining Desired Weight
Constipation/Diarrhea
Hair Loss
Other
Have you struggled with unusual constipation or loose stools?
Yes
No
Have you been diagnosed with an Autoimmune Disease or Thyroid Disorder?
Yes
No
How many doctors have you seen for this proble?
1
2
3
None
What things have you tried in the past that has not corrected your problem?
Has Medicare and or your “Healthcare” Insurance paid for the treatment(s) that you've tried above?
Yes
No
On a scale of 1-10, one being hardly any pain and ten being unbearable, how would you rate your pain?
1
2
3
4
5
6
7
8
9
10
How long have you had this problem? *
0-3 Months
3-12 Months
1-3 Years
Over 3 Years
What aspects of your life are being negatively impacted? *
Marriage/Relationships
Ability to Exercise
Work
Mood
Sleep
On a scale of 0 - 10 how important is it for you to get this problem corrected?
Is there anything else you’d like to share with us regarding your goals?
First Name
Last Name
Phone
*
Email
*
You QUALIFY for a Thyroid Consultation!! What appointment time works best for you?
Mornings
Afternoons
Evenings