This thyroid questionnaire lists symptoms and other factors most commonly found in people suffering from low thyroid or hypothyroidism. By answering this questionnaire, your scores will determine whether or not you might have low thyroid. Please answer all of the questions so we can receive your total.

After submitting your questionnaire, one of our wellness consultants will be in touch with you to discuss your score.

Please enable JavaScript in your browser to complete this form.

Name *

Phone *

Email *

Do you have fatigue? *

• Yes
• No

Do you feel lethargic? *

• Yes
• No

Do you have difficulty losing weight? *

• Yes
• No

Do you have cold hands and feet? *

• Yes
• No

Are you sensitive to the cold? *

• Yes
• No

Do you have difficulty thinking? *

• Yes
• No

Do you find it hard to concentrate? *

• Yes
• No

Do you experience brain fog? *

• Yes
• No

Do you have poor short term memory? *

• Yes
• No

Are your moods depressed? *

• Yes
• No

Are you experiencing hair loss? *

• Yes
• No

Do you have less than one bowel movement per day? *

• Yes
• No

Do you have dry skin? *

• Yes
• No

Does your skin itch in the winter? *

• Yes
• No

Do you have fluid retention? *

• Yes
• No

Do you have recurrent headaches? *

• Yes
• No

Do you sleep restlessly? *

• Yes
• No

Are you tired when you awaken? *

• Yes
• No

Do you have afternoon fatigue? *

• Yes
• No

Do you have tingling/numbness in your hands/feet? *

• Yes
• No

Do you have decreased sweating? *

• Yes
• No

Have you had problems with infertility/miscarriages? *

• Yes
• No

Do you have recurrent infections? *

• Yes
• No

Do your muscles ache? *

• Yes
• No

Do you have joint pain? *

• Yes
• No

Do you have thinning of your eyebrows or eyelashes? *

• Yes
• No

Is your tongue enlarged with teeth indentations? *

• Yes
• No

Is your skin pasty, puffy, or pale? *

• Yes
• No

Do you have decreased body hair? *

• Yes
• No

Is your voice hoarse? *

• Yes
• No

Do you have a slow pulse? *

• Yes
• No

Do you have low blood pressure? *

• Yes
• No

Does your body temperature run below 98.6°? *

• Yes
• No

Do you have sleep apnea? *

• Yes
• No

Your score has been calculated and sent to our wellness consultants. They will contact you soon to review your score with you and answer any questions you may have. If your total score is below 10 points, it is unlikely that you have low thyroid. Scoring between 11 and 30 points indicates that low thyroid is a possibility. A score above 30 points suggests that low thyroid is very likely.

Total *

Submit

Check out these short videos for more details about Thyroid function and Adrenal Fatigue.