Hashimotos &Hypothyroid Wellness 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 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 or Hypothyroidism, please email me at SarahRuth@HappyHashiMomma.com. (If you are a current client in the hashi posse, please email me or ask your questions in the respective course module).
Name
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First Name
Last Name
Email
*
example@example.com
Where did you find me?
*
Instagram
Facebook
Pinterest
TikTok
Your Website
Your social media handle for the profile you used to find me
*
Please fill this out so that way I have a second way to contact you. Most of my emails will go to spam. I will typically text message or DM you to let you know to look for my response.
Where do you live?
*
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
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
Please describe any specific details about your symptoms or provide any symptoms that were not listed above
Do you know your root cause?
Yes
No
If you know your root cause, please list or describe.
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.
Tell me about your Hashimotos/Hypothyroid journey. Are you currently following a workout regime? Have you had any testing done in the last year? If so, please list those results as well. Please feel free to list any pertinent information about how/when your symptoms started or what you've done in your journey.
What would you like to accomplish in your hashimotos journey? What are your goals?
Are you interested in nutrition, lifestyle, and supplement recommendations?
Yes
No
Please verify that you are human
*
Submit
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