Hashimotos Assessment
WHY AM I ASKING YOU TO FILL OUT THIS FORM? Hi, my name is Sarah and I was diagnosed with Hashimotos Disease in 2007. I had EVERY symptom in the book and EVERY single doctor gave me GENERIC advice on how to reverse my symptoms. I ask you to PLEASE fill out this form (adult women only) so I can put together a plan WITH you, FOR you, that isn't generic and will help you reverse your symptoms in a NON overwhelming way. If your questions are not about Hashimotos , please email me at SarahRuth@HappyHashiMomma.com.
Name
*
First Name
Last Name
Email
*
example@example.com
Where did you find me?
*
Instagram
Facebook
Pinterest
TikTok
Your Website
Where do you live? (City/State/Country)
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City, State, Country
Have you been diagnosed with Hashimotos, Hypothyroidism, Both, or Something?
Hashimotos
Hypothyroidism
Not Formally Diagnosed
Other
If you answered 'Other', please describe.
When were you diagnosed? If not diagnosed, put n/a
If you are on any medication, please list.
What are your current symptoms? Please check all that apply
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Weight gain
Weight Loss
Fatigue
Gas or Bloating
Brain Fog
Mood Swings, Anxiety, and/or Depression
Fertility Issues
Hair, Skin, or Nail Issues
Hives
Inflammation - joint, body, etc
Other
Do you know your root cause?
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Yes
No
Unsure
If yes, please list.
Are you prone to chronic sickness or infections (aka do you get sick or infections often)?
Yes
No
Don't know
Are you currently following a specific diet or nutrition protocol? Please describe. If you know your caloric intake and macros, please provide those as well.
In the last 7 days, how closely have you followed that plan?
0-25%
26-50%
51-75%
76-100%
What’s your biggest nutrition struggle right now? (Planning, cravings, eating out, family resistance, not knowing what to eat, etc.)
Have you had any testing done in the last year? (Yes / No) If yes, please list what kind and any key results you know.
Have you reviewed these results with a functional/holistic provider before? If yes, what did they say? If no, what questions do you still have?
On a scale of 1–10, how committed are you to making changes in your habits to heal?
What changes are you already making to support your healing?
What has stopped you from reaching your health goals so far? (Select all that apply)
Lack of clear plan
Not knowing what actually works my Hashimoto’s
Busy lifestyle/time constraints
Conflicting information online
Lack of accountability/support
Fear of failing again
Other
What are your top 3 health goals for the next 6–12 months?
If you woke up 6 months from now feeling amazing, what would be different in your body and life?
How would that impact your day-to-day life and relationships?
Please verify that you are human
*
Submit
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